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THE   DIAGNOSIS 

OF 

NERVOUS    AND    MENTAL    DISEASES 


PERSHING 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/diagnosisofnervOOpers 


THE  DIAGNOSIS 

OF 

Nervous  and  Mental 
Diseases 


HOWELL   T.    PERSHING,  M.Sc,  M.D. 

PROFESSOR    OF    NERVOUS    AND    MENTAL  DISEASES    IN    THE  UNIVERSITY  OF    DENVER 

NEUROLOGIST  TO  ST.  LUKE'S  HOSPITAL,  CONSULTANT  IN  NERVOUS  AND  MENTAL 

DISEASES     TO    THE     ARAPAHOE    COUNTY     HOSPITAL,     MEMBER     OF     THE 

AMERICAN  NEUROLOGICAL  ASSOCIATION. 


ILLUSTRATED. 


PHILADELPHIA : 
P.    BLAKISTON'S    SON   &    CO 

IOI3    WALNUT    STREET, 
I9OI 


Copyright,  1901,  by 
P.  Blakiston's  Son  &  Co. 


PREFACE. 

The  object  of  this  book  is  to  facilitate  the  recognition  of 
nervous  and  mental  diseases  by  physicians  who  are  not 
specialists  in  neurology.  It  makes  no  attempt  to  add  to 
the  facts  of  medicine  but  aims  simply  to  set  forth  a  practi- 
cal method  of  diagnosis  in  as  convenient  and  compact  a 
form  as  possible. 

Neurological  diagnosis  presents  peculiar  difficulties  for 
those  who  have  not  been  specially  trained  in  it.  A 
thorough  examination  must  be  followed  by  a  complicated 
train  of  reasoning  in  which  there  are  many  possibilities  of 
error.  To  avoid  the  difficulties  by  leaving  them  all  to  the 
neurologist  is  impracticable,  for  cases  of  nervous  disease, 
often  simulating  other  maladies,  are  sure  to  come  to  every 
one  who  practices  medicine,  even  to  the  specialist  who  has 
least  to  do  with  neurology. 

In  trying  to  teach  an  available  method  of  diagnosis,  med- 
ical writers  may  well  adopt  a  plan  extensively  used  in  other 
sciences.  The  student  of  botany  does  not  have  to  carry  in 
mind  the  characters  of  all  the  species  he  may  possibly  meet 
in  order  to  find  the  name  and  classification  of  any  speci- 
men in  which  he  may  be  interested.  He  is  provided  with  a 
table,  or  "  key,"  in  which  there  is  a  condensed  description 
of  all  the  classes,  orders,  genera  and  species,  so  arranged 
that,  having  made  a  proper  examination  of  the  specimen, 
he  can  rapidly  find  the  divisions  and  subdivisions  to  which 
it  belongs.  The  same  method  is  used  with  great  advan- 
tage in  zoology,  chemistry  and  mineralogy.  Of  all  the 
branches  of  medicine,  neurology  is  the  one  to  which  it  is 
most  applicable. 


PREFACE. 


Some  years  ago,  for  the  use  of  my  classes,  I  began  the 
construction  of  a  series  of  diagnostic  tables,  under  such 
general  heads  as  Hemiplegia,  Paralysis  of  Ocular  Muscles, 
Optic  Neuritis,  Headache,  etc.,  adopting  the  form  of  a 
botanical  key.  These  tables  have  grown  until  they  pretty 
fairly  cover  the  field  of  neurological  diagnosis  and  they 
are  offered  to  the  profession  in  the  hope  that  they  will  be 
practically  useful  as  an  outline  map  of  the  field.  They 
aim  to  show,  explicitly  but  briefly,  what  symptoms  are  the 
most  important  in  a  given  case  of  nervous  disease,  and 
how  an  analysis  of  the  symptoms  should  lead  to  the  recog- 
nition of  the  disease ;  in  other  words  they  attempt  to  show 
on  paper  what  a  neurologist  would  have  in  mind  in  con- 
firming his  diagnosis,  step  by  step.  As  an  intelligent  use 
of  the  tables  presupposes  a  knowledge  of  the  essential 
features  of  the  case  under  consideration  and  the  ability  to 
recognize  certain  general  conditions,  they  are  preceded  by 
a  description  of  the  methods  of  examination  and  a  brief 
discussion  of  the  signs  of  organic  disease,  hysteria  and 
neurasthenia. 

It  is  of  course  understood  that  such  an  outline  of  diag- 
nosis should  be  used  as  an  adjunct  to  some  complete  trea- 
tise on  nervous  diseases  and  one  of  the  hopes  entertained 
by  the  writer  is  that  it  will  make  the  fuller  knowledge  of 
the  best  text-books  more  readily  accessible  to  the  busy 
physician. 


CONTENTS. 


EXAMINATION    OF    THE    PATIENT    AND    THE     GENERAL    SIG- 
NIFICANCE   OF    SYMPTOMS  .  .  .  .17 

Blank  Forms  for  Recording  Cases  .......     17 

Family  Histoi-j         .         .         .         .         .         .         .         .         .         •     I'J 

Personal  History       ..........     18 

Previous  Illnesses  or  Injuries.         .         .         .         .         .         .         .18 

Mode  of  Onset  and  Course  of  Present  Illness.         .         .         .         .18 

Present  Sufferings    .         .         .         .         .         .         .         .         .         .18 

Nervous  Spells.         ..........     18 

Syphilis  and  Other  Sexual  Disorders       ......     19 

Alcoholic  Excess       ..........     20 

Uric  Acid  Diathesis.         .........     20 

Causes  of  Exhaustion       .         .         .  .         .  .         .         .         .21 

Importance  of  Studying  Mental  Peculiarities.         .         .         .         .21 

Present  Condition    ..........     22 

General  Appearance  .........     22 

Motor  Disorders       ..........     23 

Electrical  Reactions  and  Trophic  Condition  of  Muscles.         .         .     30 
The  Reiiexes     ...........     40 

Tests  of  Cutaneous  Sensibility         .......     48 

Posture  Sense  ...........     53 

Taste  and  Smell 53 

Examination  of  the  Ear  .........     53 

Examination  of  the  Eye  .........     154 

Examination  as  to  Speech        ........     64 

Examination  as  to  Mental  Condition       .         .         ...         .         -65 


THE    RECOGNITION    OF    ORGANIC    DISEASE 
THE    PRINCIPLES    OF    LOCALIZATION    . 
THE    SIGNS    OF    HYSTERIA  . 
THE    DIAGNOSIS    OF    NEURASTHENIA     . 
MIXED    FORMS    OF    DISEASE 


69 

74 
78 

84 

86 


CONTENTS. 


THE    RECOGNITION    OF    SPECIAL    DISEASES   .         .  .  .87 

Explanation  of  Tables      .........     87 

Diseases  Which  May  Cause  Hemiplegia  .         .         .         .         .89 

Localization  Diagnosis  in  Hemiplegia    ......     94 

Partial  Hemiplegia  and  Monoplegia         .         .         .  .        '.  .96 

Localization  Diagnosis  in  Partial  Hemiplegia  and  Monoplegia      .     99 
Paraplegia  and  Double  Hemiplegia  ......    100 

Localization  Diagnosis  in  Paraplegia  and  Double  Hemiplegia       .   107 
Paralysis  of  Ocular  Muscles     .         .  .         .         .         .         .  .111 

Localization  Diagnosis  in  Paralysis  of  Ocular  Muscles  .         .         .    120 
Facial  Paralysis         ..........   123 

Bulbar  and  Pseudo-bulbar  Paralysis         ......    125 

Laryngeal  Paralysis  .         .         .  .         .         .         .         .         .128 

Paralysis  of  Partial  or  Irregular  Extent  ......   130 

Ataxia       ............   136 

Tremor     ............   139 

General  Spasms        .         .         .         .         .         .         .         .         .         .   iz|2 

Localized  Spasms     ..........   149 

Optic  Neuritis  ...........   159 

Optic  Atrophy  .         .         .         .         .         .         .         .         .         .   165 

Trophic  and  Vaso-motor  Symptoms        ......   169 

The  Pains  of  Nervous  Disease  .......   174 

Vertigo .         .193 

Coma        ............   197 

Disorders  of  Speech  .........   199 

Insanity    ............  205 


THE    DIAGNOSIS 


Nervous  and  Mental  Diseases 


EXAMINATION    OF    THE    PATIENT    AND 

THE   GENERAL    SIGNIFICANCE 

OF    SYMPTOMS. 

In  order  to  be  thorough  the  neurological  examination 
must  follow  an  orderly  routine.  In  any  case  involving 
difficulties  of  diagnosis  or  treatment  it  is  true  economy  of 
time  and  labor  to  get  all  the  available  data  and  accurately 
record  them  at  the  beginning,  making  such  additional 
notes  from  time  to  time  as  new  facts  may  require.  For 
this  purpose  loose  sheets  of  paper  with  printed  headings, 
properly  arranged,  are  most  convenient,  although  an  ordi- 
nary record  book  may  be  used. 

FAMILY    HISTORY. 

After  getting  a  general  idea  of  the  patient's  complaint 
and  making  the  usual  notes  of  the  name,  age,  race,  domes- 
tic condition  and  occupation,  inquiry  is  to  be  made  as  to  the 
family  history.  The  state  of  health,  if  living,  or  the  age 
at  death  and  cause  of  death,  should  be  noted  of  each 
of  the  parents,  grandparents,  brothers  and  sisters.  Care 
should  be  taken  not  to  overlook  the  existence,  in  any  of 
the  near  relatives,  of  nervous  or  mental  disease,  tuber- 
2  17 


l8  NERVOUS    AND    MENTAL    DISEASES. 

culosis,  rheumatism  or  gout,  and  a  general  denial  on  the 
part  of  the  patient  should  be  supplemented  by  specific  in- 
quiries, extending  often  to  the  history  of  the  uncles  and 
aunts. 

PERSONAL    HISTORY. 

The  salient  points  in  the  personal  history  prior  to  the 
present  illness  are  first  to  be  noted  in  chronological  order, 
after  which  the  history  of  the  present  illness  is  to  be  ob- 
tained with  special  reference  to  the  first  symptoms  and 
their  mode  of  onset,  whether  sudden,  rapid  or  slow,  the 
order  in  which  the  subsequent  symptoms  have  appeared 
and  the  patient's  complaints  at  the  time  of  examination. 
Skilful  questioning  will  be  necessary  to  bring  out  the  full 
history  and  it  should  be  definite  in  regard  to  the  following 
subjects  : 

1.  Injury  at  birth. 

2.  Damage  to  the  nervous  system  by  previous  diseases, 
such  as  scarlatina,  influenza,  meningitis,  etc.,  or  by  injury. 

3.  Convulsions  or  nervous  spells  of  any  kind. 

4.  Syphilitic  infection. 

5.  Other  diseases  of  the  sexual  organs,  real  or  imagi- 
nary, and  sexual  excesses. 

6.  Habits  as  to  alcohol,  tobacco  and  other  possible 
poisons. 

7.  The  uric  acid  diathesis. 

8.  Exhausting  influences  and  signs  of  exhaustion. 

9.  Abnormal  suggestibility,  morbid  fears,  hypochon- 
driacal worry  and  other  signs  of  mental  instability. 

Possible  injury  at  birth  is  of  especial  importance  when 
paralysis,  spasm  or  arrest  of  development  dates  from 
infancy. 

If  convulsions  or  nervous  spells  of  any  kind  have  oc- 
curred care  is  to  be  taken  to  ascertain  when  they  began, 
how  often   they   have  recurred   and  under  what   circum- 


EXAMINATION    OF    THE    PATIENT.  I9 

stances,  as  well  as  to  get  an  accurate  description  of  them. 
It  must  be  remembered  that  some  symptoms,  such  as  at- 
tacks of  fetit  mal,  are  not  likely  to  be  mentioned  unless  the 
examiner  asks  specifically  about  them  and,  on  the  other 
hand,  that  leading  quesdons  will  often  elicit  totally  incor- 
rect answers. 

Syphilis  is  so  common  a  cause  of  headache,  neuralgia, 
and  many  grave  organic  affections  and  so  much  depends 
on  early  specific  treatment  that  it  is  difficult  to  exaggerate 
the  importance  of  its  prompt  recognition.  There  need  be 
no  hesitation  about  asking  any  male  patient  whether  ven- 
ereal infection  has  occurred  and  cross-examining  him  if 
the  answer  is  negative.  When  the  direct  question  cannot 
be  asked,  as  in  the  case  of  most  women,  or  when  the  an- 
swers are  inconclusive,  the  examiner  must  be  alive  to  the 
significance  of  the  symptoms  of  syphilis,  such  as  the  erup- 
tions, mucous  patches,  nasal  ulcers,  alopecia,  keratitis, 
iritis,  choroiditis,  nodes  on  bones  or  cartilages,  enlarged 
glands,  nocturnal  headache,  etc.  When  hereditary  syph- 
ilis is  suspected  inquiry  is  to  be  made  as  to  snuffles,  emaci- 
ation, eruption  and  parchment-like  character  of  the  palms 
and  soles  in  early  infancy. 

The  history  as  to  sexual  disorders  other  than  syphilis  is 
important  because  they  occasionally  cause  reflex  pains  and 
very  often  are  a  source  of  exhaustion  or  worry.  Worry- 
ing about  an  imaginary  disease  may  be  far  more  harmful 
than  the  ph3^sical  effects  of  the  real  disease,  so  patients 
should  be  induced  to  express  themselves  freely.  Many  a 
man  carries  a  mental  burden  for  months  or  even  years  be- 
cause he  has  an  occasional  seminal  emission  or  has  dis- 
covered a  little  mucus  at  the  meatus,  which  he  fancies  to 
be  an  exhausting  seminal  discharge,  or  because  he  has  dis- 
covered the  normal  epididymis  or  the  veins  of  the  sper- 
matic cord   or  that  the  left  testicle  hangs  lower  than   the 


20  NERVOUS    AND    MENTAL    DISEASES. 

right.  That  a  nervous  woman's  mind  is  often  fixed  upon 
her  pelvic  organs  to  her  great  detriment  is  well  known  to 
every  physician.  A  morbid  idea  of  this  kind  often  con- 
stitutes a  mental  traumatism  which  is  the  most  important 
fact  in  the  case,  and  the  removal  of  the  idea  may  be  the 
most  difficult  as  well  as  the  most  essential  part  of  the 
treatment. 

A  true  estimate  of  the  effects  of  sexual  excesses  and  of 
masturbation  requires  careful  discrimination.  In  many 
cases  these  vices  are  an  important  physical  cause  of  ex- 
haustion, but  in  many  other  cases  the  fear  and  remorse  oc- 
casioned by  past  errors  are  of  serious  import  while  the 
physical  effects  are  insignificant. 

The  intemperate  use  of  alcohol  is  generally  freely  con- 
fessed by  men  but  often  denied  by  women,  who  are  more 
apt  to  drink  secretly  if  at  all.  When  excessive  drinking  is 
not  confessed,  alcoholism  may  be  revealed  by  a  history  of 
gastric  catarrh  with  morning  vomiting,  delirium  tremens 
or  multiple  neuritis  with  the  mental  state  characteristic  of 
the  alcoholic  form. 

The  possibility  of  poisoning  by  lead,  arsenic,  mercury, 
carbon  disulphid  or  other  toxic  agents  may  have  to  be  con- 
sidered, especially  in  connection  with  the  patient's  occupa- 
tion. 

The  uric  acid  diathesis  is  a  very  important  factor  in  the 
etiology  of  headache,  neuralgia,  sciatica,  neurasthenia  and 
mental  depression,  as  well  as  of  ordinary  gout  and  rheu- 
matism. No  uncertainty  as  to  its  essential  cause  should 
prevent  its  full  recognition  in  diagnosis  and  treatment.  A 
history  of  muscular  or  articular  pains  without  organic  cause, 
or  of  repeated  attacks  of  tonsillitis,  pharyngitis  or  eczema, 
or  of  so-called  bilious  attacks,  or  even  a  history  of  head- 
ache or  despondency  habitually  worse  in  the  early  morning, 
ought  always  to  suggest  the  possibility  of  this  condition 


EXAMINATION    OF    THE    PATIENT.  21 

being  the  cause.  If  further  inquiry  shows  that  the  urine  is 
often  dark  and  sometimes  deposits  urates  the  possibility  be- 
comes a  probability. 

The  causes  of  nervous  exhaustion,  such  as  the  infectious 
diseases,  repeated  pregnancies,  lactation,  overwork,  anxiety 
and  grief,  are  generally  clearly  indicated  in  the  patient's 
accovmt.  The  signs  of  exhaustion,  such  as  early  fatigue, 
irritability,  lack  of  zest  for  work  and  a  loss  of  the  former 
ambitions  and  interests,  are  also  likely  to  receive  prominent 
mention.  More  often  overlooked  is  the  fact  that  moral 
delinquencies,  such  as  neglect  of  plain  duties,  cowardice, 
addiction  to  stimulants  and  narcotics  and  offenses  growing 
out  of  irrational  antipathies  or  unrestrained  impulses,  may 
have  their  origin  in  exhaustion,  especially  in  patients  of 
neurotic  inheritance. 

In  functional  nervous  disorders  it  is  of  the  greatest  im- 
portance for  diagnosis  and  treatment  that  the  facts  in  the 
personal  history  which  reveal  the  patient's  mental  peculiari- 
ties should  be  fully  noted.  If  the  patient  tells  of  most  ex- 
traordinary effects  of  medicines,  of  queer  sensations  felt  on 
the  approach  of  a  thunder  storm  or  while  riding  in  an  elec- 
tric car,  or  of  severe  pains  or  profound  emotional  disturb- 
ance caused  by  some  trivial  occurrence,  the  physician,  in- 
stead of  controverting  the  statements  at  this  time,  should 
be  an  interested  and  sympathetic  listener,  and  so  lead  the 
conversation  as  to  get  a  full  understanding  of  the  degree  of 
emotional  instability  and  susceptibility  to  suggestion.  For 
the  same  reason,  if  the  patient  is  afraid  to  go  into  the  street 
alone,  or  is  absurdly  convinced  that  his  heart  is  seriously 
diseased,  he  is  not  to  be  laughed  at,  but  encouraged  to  tell 
the  whole  of  his  troubles. 

Failure  to  elicit  this  part  of  the  history  often  causes  fail- 
ure in  the  management  of  the  case  when  better  methods 
would  insure  success.     Even  if  the  diagnosis  be  correct,  a 


22  NERVOUS    AND    MENTAL    DISEASES. 

plan  of  treatment  which  is  perfect  on  the  physical  side  may 
be  rendered  useless  by  a  mistaken  idea  on  the  part  of  the 
patient  that  he  cannot  stand  some  of  the  remedies  or  that 
his  first  temporary  backset,  after  a  period  of  improvement, 
shows  the  futility  of  continuing  on  the  same  plan.  On  the 
other  hand,  the  mental  peculiarities  which  are  a  source  of 
danger  may  be  made  the  means  of  securing  confidence, 
obedience  and  unfaltering  constancy  by  a  physician  who 
understands  them.  The  psychologic  management  of  neu- 
rotic patients  is  a  difficult  art  which  can  hardly  be  taught 
on  paper,  but  it  is  so  important  a  means  of  success  that 
every  young  practitioner  should  make  a  conscious  effort  to 
acquire  it.  The  three  questions  to  be  kept  in  mind  when 
taking  a  history  of  such  a  patient  are  :  "  What  light  do  the 
mental  characteristics  of  the  patient  throw  upon  the  diag- 
nosis of  his  case?"  "  What  is  there  in  his  mental  constitu- 
tion which  may  endanger  the  sviccess  of  treatment?"  and 
"  How  can  his  peculiarities  be  made  to  contribute  to  a  suc- 
cessful result?  " 

It  is  hardly  necessary  to  remind  even  the  beginner  in 
neurology  that  he  should  not  express  an  opinion  based  on 
the  history  alone,  but  should  always  proceed  to  a  thorough 
physical  examination. 

THE    PRESENT    CONDITION. 

The  objective  examination  should  be  begun  by  observing 
the  general  appearance  as  to  vigor,  color,  state  of  nutrition 
and  expression  of  the  face.  Any  abnormality  in  the  size 
or  conformation  of  the  head  or  any  of  its  parts  will  be  ob- 
served at  the  same  time.  The  actual  bodily  weight  should 
be  noted  for  comparison  with  its  amounts  in  the  past  and 
in  the  future.  At  least  a  cursory  examination  should  be 
made  in  any  case  into  the  condition  of  the  heart,  lungs, 
abdominal  organs   and  urine,  and  elaborate  investigations 


EXAMINATION    OF    THE    PATIENT.  23 

may  be  necessary  in  special  cases.  The  urine,  in  par- 
ticular, must  often  be  examined  with  the  greatest  care,  for 
uremia  causes  a  great  variety  of  nervous  symptoms  and  it 
is  by  no  means  excluded  by  the  failure  to  find  albumen. 
In  all  doubtful  cases  the  chemical  tests  should  be  supple- 
mented by  microscopic  examination  and  a  consideration  of 
the  total  quantity  and  specific  gravity  of  the  urine  passed 
in  24  hours. 

MOTOR     DISORDERS. 

The  motor  disorders  to  be  looked  for  are  paralysis, 
ataxia,  spasm  and  tremor.  As  a  general  test  of  motility 
let  the  patient  walk  forward  and  backward,  turn  and  stand 
on  either  foot,  first  with  eyes  open  and  then  with  eyes 
closed.  Next  let  him  grasp  the  examiner's  hands  as 
strongly  as  possible  and  afterward  hold  out  both  hands  with 
the  fingers  spread  apart,  then,  with  eyes  closed,  touch  the 
tip  of  the  nose  with  each  forefinger  and  bring  the  tips  of 
the  forefingers  together  before  the  face,  above  the  head  and 
behind  the  back.  Then  have  him  draw  up  the  corners  of 
the  mouth  as  though  to  show  the  upper  teeth,  close  the 
eyes  tightly,  wrinkle  the  forehead,  so  as  to  open  the  eyes 
as  widely  as  possible,  and  protrude  the  tongue.  If  all 
these  actions  are  readily  performed  without  any  abnor- 
mality being  observed  motor  disorders  of  the  limbs,  face 
and  tongue  are  excluded  and  the  examiner  may  proceed  to 
test  the  reflexes.  But  if  any  abnormality  is  revealed  a 
complete  investigation  will  be  necessary. 

An  abnormal  gait  may  conform  to  any  one  of  a  number 
of  widely  differing  types  which  can  best  be  understood  by 
comparison  with  a  normal  gait.  In  normal  walking,  while 
the  weight  of  the  body  rests  upon  one  leg,  the  other  is 
swung  forward  like  a  pendulum  hanging  from  the  hip. 
The  swinging  foot  is  kept  clear  of  the  ground  partly  be- 
cause the  hip  is  slightly  raised  by  the  motion  which  throws 


24  NERVOUS    AND    MENTAL    DISEASES. 

the  weight  of  the  body  upon  the  fixed  leg,  but  mainly  be- 
cause the  moving  limb  is  shortened  by  flexion  of  the  knee 
and  dorsal  flexion  of  the  foot.  All  pathological  changes  of 
gait  are  caused  by  something  which  prevents  the  proper 
support  of  the  body  by  the  fixed  leg  or  the  proper  forward 
swing  of  the  moving  one. 

In  the  gait  characteristic  of  simple  weakness,  as  in  ex- 
treme exhaustion  or  after  typhoid  fever  or  in  old  age,  the 
steps  are  short  and  slow.  The  knees  feel  as  though  about 
to  give  way  and  may  visibly  bend  under  the  weight  of  the 
body.  In  extreme  cases  the  patient  grasps  surrounding 
objects  for  support. 

The  gait  of  ordinary  hemiplegia  owes  its  peculiarity  to 
the  fact  that  on  the  paralyzed  side  flexion  of  the  knee  and 
dorsal  flexion  of  the  foot  are  especially  weak  so  that,  as 
the  paralysis  is  spastic,  the  limb  is  held  in  rather  rigid  ex- 
tension. When  it  should  swing  forward  the  heel  is  raised 
with  difficulty  and  it  is  still  more  difficult  to  sufficiently  raise 
the  toe.  It  is  as  though  the  limb  were  too  long  and  the 
foot  would  remain  planted  on  the  ground  were  it  not  for 
two  extra  motions,  by  which  the  patient,  as  far  as  possible, 
obviates  the  difficulty.  He  leans  excessively  toward  the 
sound  side,  thus  elevating  the  hip  on  the  paralyzed  side, 
and  then  gives  the  paralyzed  limb  an  outward  swing  so  as 
to  bring  it  around  in  advance  of  the  sound  one.  The  mo- 
tion resembles  the  swing  of  a  scythe,  the  foot  pointing  out- 
ward and  representing  the  blade.  There  is  generally  little 
difficulty  in  supporting  the  body  while  the  sound  limb  is 
brought  forward,  as  the  extensors  of  the  paralyzed  limb  are 
relatively  strong.  Recognition  of  this  form  of  paralysis  is 
made  especially  easy  by  the  posture  of  the  paralyzed  arm 
which,  in  a  typical  case,  is  held  close  to  the  body  and 
flexed  at  the  elbow,  wrist  and  fingers.  Weakness  of  the 
lower  part  of  the  face  may  also  be  apparent. 


EXAMINATION    OF    THE    PATIENT.  25 

The  gait  characteristic  of  hysterical  paralysis  of  one  leg 
is  very  different  from  that  of  organic  hemiplegia,  just  de- 
scribed, and  resembles  that  of  children  who  imitate  lame- 
ness in  their  play.  The  paralyzed  limb  is  dragged  after 
the  sound  one,  not  swung  around  it  nor  placed  in  advance. 
The  foot  is  often  held  at  right  angles  to  the  leg  so  firmly 
as  to  show  that  there  is  no  weakness  of   its  dorsal  flexors. 

In  the  gait  of  spastic  paraplegia  both  lower  limbs  are  in 
nearly  the  same  condition  as  the  paralyzed  one  in  organic 
hemiplegia  and  the  difliculty  is  to  get  one  foot  in  advance 
of  the  other.  To  accomplish  this  the  patient  leans  for- 
ward and  to  the  side  opposite  the  limb  about  to  be  moved 
which  is  then  stiffly  swung  forward  as  one  piece,  the  foot, 
especially  the  toes,  dragging  on  the  floor.  Spasm  of  the 
adductors  may  cause  the  thighs  to  rub  together  and  even 
to  cross.  The  accompanying  exaggeration  of  the  tendon 
reflexes  may  be  so  great  as  to  cause  ankle  clonus  to  be 
elicited  as  the  foot  is  planted  and  the  weight  of  the  body 
thrown  upon  it. 

The  steppage  gait,  characteristic  of  multiple  neuritis,  is 
caused  by  a  flabby  paralysis  of  the  dorsal  flexors  of  the 
foot  on  both  sides.  When  the  heel  is  raised  the  foot  hangs 
down  of  its  own  weight.  In  order  that  the  toe  may  clear 
the  ground  the  heel  must  be  raised  by  an  exaggerated  flex- 
ion of  the  hip  and  knee,  much  higher  than  it  normally  is 
and  then  the  dangling  foot  is  flung  forward,  the  toe  com- 
ing down  first.  The  action  is  somewhat  suggestive  of  that 
of  a  high-stepping  horse.  Poliomyelitis  often  causes  a 
similar  defect  but  it  is  usually  unequal  on  the  two  sides. 

Weakness  of  one  leg,  especially  if  there  is  no  rigidity, 
causes  a  limp,  because  the  weight  of  the  body  is  not  trusted 
on  the  weak  leg  longer  than  necessary,  and  the  patient 
hastens  to  plant  the  sound  foot  and  bring  the  weight  on  it, 
thus  exaggerating  the  foot-fall  on  the  sound  side.     The 


26  NERVOUS    AND    MENTAL    DISEASES. 

same  kind  of  limping  is  caused  by  any  condition  of  one  leg 
which  makes  it  painful  for  it  to  bear  the  weight  of  the 
body. 

If  an  abnormal  gait  or  a  defective  movement  in  the 
upper  part  of  the  body  indicates  any  form  of  paralysis, 
each  movement  should  be  tested  separately. 

The  power  to  move  a  joint  may  be  tested  by  three  meth- 
ods :  I.  The  patient  is  told  to  move  the  joint  vigorously  in 
each  of  its  possible  ways,  flexion,  extension,  adduction, 
abduction,  etc.  If  motion  is  not  free  or  vigorous  in  any 
direction,  care  should  be  taken  to  make  sure  that  the  limi- 
tation is  not  due  to  mechanical  conditions,  such  as  disease 
of  the  joint  or  shortening  of  the  opposing  muscles.  2.  The 
patient  is  told  to  make  the  same  motions  as  strongly  as 
possible  while  the  examiner  resists  them  and  thus  estimates 
their  force.  3.  The  patient  is  told  to  hold  the  joint  in  each 
position  while  the  examiner  tries  to  force  it  into  the  opposite 
position.  In  many  cases  the  third  of  these  methods  gives 
the  most  reliable  results.  These  tests  may  be  varied  and 
extended  by  having  the  patient  stoop  and  rise  on  one  leg, 
stand  on  tiptoe,  mount  a  chair,  pick  up  an  object  from  the 
floor,  arise  from  a  recumbent  position,  form  a  ring  with  the 
thumb  and  forefinger,  etc. 

Paralysis  of  one  side  of  the  face  is  indicated  by  compara- 
tive smoothness  of  that  side  in  repose  and  by  less  movement 
than  occurs  on  the  sound  side  in  whistling,  showing  the 
upper  teeth,  closing  the  eyes  arid  wrinkling  the  forehead. 
When  the  weakness  of  the  lips  is  slight  it  may  best  be  de- 
tected by  putting  the  tip  of  a  finger  between  them  on  either 
side  and,  while  the  patient  tries  to  compress  it  as  firmly  as 
possible,  pushing  upward  and  downward  so  as  to  estimate 
their  muscular  power.  Slight  weakness  of  one  orbicularis 
■palpebrarum  may  be  detected  by  trying  to  open  the  lids 
with  the  fingers  while  the  patient  tries  to  keep  them  closed 


EXAMINATION    OF    THE    PATIENT.  27 

and  also  by  noting  the  patient's  inability  to  close  the  eye  on 
the  weakened  side  without  at  the  same  time  closing  the 
other.  Bilateral  paralysis  of  the  face  is  not  so  easily  de- 
tected but  when  considerable  in  degree  it  is  revealed  by 
lack  of  expression  and  defect  of  movement  on  both  sides. 

Unilateral  paralysis  of  the  tongue  is  shown  by  deviation 
to  the  paralyzed  side  when  it  is  protruded,  bilateral  paral- 
ysis by  inability  to  protrude  it  and  difficulty  in  pushing  solid 
food  from  the  mouth  into  the  pharynx  in  the  first  part  of 
deglutition. 

Paralysis  of  the  palate  causes  a  muffled,  nasal  sound  of 
the  voice,  inability  properly  to  utter  the  explosive  consonants 
(b,  p,  d,  t,  g,  k),  or  to  puff  as  in  blowing  out  a  candle,  and 
regurgitation  of  liquid  food  through  the  nose.  The  absence, 
on  one  or  both  sides,  of  the  elevation  of  the  soft  palate 
which  normally  occurs  on  saying  "  Ah,"  can  be  seen  by 
direct  inspection. 

Paralysis  of  the  pharynx  causes  difficulty  in  pushing 
food  into  the  esophagus  after  it  has  passed  the  fauces. 

Paralysis  of  the  laryngeal  muscles  causes  alterations  of 
voice  and  sometimes  difficulty  of  breathing  and  is  recog- 
nized with  certainty  by  the  observation,  with  the  laryngo- 
scope, of  defective  movement  of  one  or  both  vocal  cords 
in  respiration  and  phonation.  For  details  the  reader  is  re- 
ferred to  a  text-book  of  laryngology.  Unilateral  paralysis 
of  any  of  the  laryngeal  muscles  is  always  caused  by  organic 
disease. 

Thus  far  the  directions  for  examination  have  presupposed 
the  cooperation  of  the  patient,  but  it  is  often  of  the  greatest 
importance,  especially  after  apoplectic  attacks  and  injuries 
of  the  head,  to  recognize  paralysis  while  the  patient  is  un- 
conscious. In  such  cases  the  paralysis  is  almost  always  in 
the  form  of  a  partial  or  complete  hemiplegia  which  will  be 
revealed  by  a  careful  comparison  of  the  two  sides  of  the 


28  NERVOUS    AND    MENTAL    DISEASES. 

body.  The  eyes  and  head  are  often  turned  away  from  the 
paralyzed  side  and  if  the  head  is  forcibly  turned  to  this  side 
it  soon  goes  back  to  its  former  position.  This  is  called 
conjugate  deviation  of  the  head  and  eyes.  The  corner  of 
the  mouth  is  drawn  down,  the  naso-labial  fold  is  partly  or 
wholly  obliterated  and  the  cheek  may  flap  more  in  expira- 
tion on  the  paralyzed  side. 

On  inspecting  the  limbs  it  may  be  noticed  that  those  on 
one  side  are  moved  while  the  opposite  ones  are  quiet. 
Moreover,  the  superficial  reflexes  and  even  the  tendon  re- 
flexes on  the  paralyzed  side  are  likely  to  be  lost  or  dimin- 
ished in  this  early  stage,  although  later  the  tendon  reflexes 
will  be  increased.  On  raising  the  arms  and  letting  go  of 
them  at  the  same  time  the  paralyzed  one  is  seen  to  drop 
more  quickly  and  limply  than  the  other,  and  the  same  test 
may  be  applied  to  the  legs. 

Ataxia,  or  incoordination,  may  exist  with  or  without 
paralysis,  and  sometimes  causes  a  striking  abnormality  of 
gait  when  no  paralysis  can  be  detected.  There  are  two 
distinct  forms  of  ataxic  gait,  that  due  to  disease  of  the  sen- 
sory tracts  of  the  spinal  cord,  as  in  tabes  dorsalis,  and  that 
due  to  disease  of  the  cerebellum  or  of  structures  adja- 
cent to  it. 

In  the  ataxic  gait  of  spinal  disease  the  incoordination  is 
due  to  the  fact  that  interference  with  the  sensory  impulses 
from  the  moving  limbs  prevents  the  patient  from  being 
aware  at  each  instant  of  their  posture  and  the  force  of 
their  muscular  contractions  and  so  from  having  a  correct 
idea  of  the  motion  which  should  follow.  The  result  is  that 
he  sways  more  than  is  normal,  walks  with  the  feet  far 
apart,  steps  too  high,  brings  the  foot  down  too  hard,  the 
heels  striking  first,  and  keeps  the  eyes  fixed  on  the  ground 
ahead  of  him,  so  as  to  make  vision  compensate  as  far  as 
possible  for  the  defect  in  posture  sense.     Closing  the  eyes 


EXAMINATION    OF    THE    PATIENT.  29 

greatl}'  increases  the  difficulty  in  walking  and  a  degree  of 
ataxia  too  slight  to  be  detected  when  the  eyes  are  open  may 
be  quite  apparent  when  they  are  closed.  The  ability  to 
stand  steadily  with  the  eyes  closed  is  even  more  affected 
than  the  ability  to  walk.  When  the  patient  attempts  it  he 
sways  much  more  than  he  would  if  in  health.  This  sway- 
ing is  known  as  Romberg's  symptom,  or  ataxia  of  station. 
A  very  delicate  test  for  ataxia  of  station  is  to  have  the  pa- 
tient try  to  stand  on  either  foot  with  the  eyes  closed ;  if  he 
can  do  this  without  difficulty  ataxia  in  the  lower  limbs  is 
excluded. 

The  gait  of  cerebellar  ataxia  may  sometimes  appear  to 
be  like  that  of  spinal  ataxia,  but  is  generally  clearly  dis- 
tinguished by  a  tendency  to  reel  from  side  to  side,  as  in 
ordinary  drunkenness,  a  tendency  which  is  but  slightly  in- 
creased by  closing  the  eyes. 

Ataxia  of  the  upper  limbs  is  indicated  by  an  irregular 
deviation  of  the  hand  in  trying  to  touch  the  nose  with  the 
tip  of  the  forefinger  or  to  bring  the  tips  of  the  forefingers 
together.     It  is  much  increased  by  closing  the  eyes. 

Ataxia  of  the  muscles  of  the  trunk  is  shown  by  swaying 
on  trying  to  sit  steadily  erect  without  such  support  as  the 
back  of  a  chair  would  give. 

Tremor  is  a  symptom  so  familiar  that  it  calls  for  no  spe- 
cial description,  but  care  should  be  taken  to  note  what  parts 
tremble,  the  character  of  the  tremor,  whether  fine  or  coarse, 
rapid  or  slow,  regular  or  irregular,  and  under  what  condi- 
tions it  occurs.  When  it  occurs  only  on  attempting  a  move- 
ment, as  in  disseminated  sclerosis,  it  is  called  intention 
tremor.  The  flickering  tremor  of  small  parts  of  a  muscle, 
seen  when  motor  nuclei  are  degenerating,  and  the  facial 
tremor  of  paretic  dementia  are  of  especial  importance. 

Spasm,  or  abnormal  involuntary  muscular  contraction, 
is  generally  easily  recognized.     The  most  important  things 


30  NERVOUS    AND    MENTAL    DISEASES. 

to  note  concerning  it  are  whether  it  is  tonic  or  clonic,  and 
whether  it  affects  the  whole  or  part  of  a  single  muscle,  a 
group  of  muscles  or  the  muscular  system  generally. 

ELECTRICAL    REACTIONS    AND    TROPHIC    CONDITIONS 
OF    MUSCLES. 

The  most  useful  electrical  test  is  that  of  faradic  irritabil- 
ity. It  is  easily  made  by  placing  one  electrode  of  a  faradic 
battery  over  the  motor  point  of  the  muscle  (the  point  where 
the  principal  nerve  enters)  and,  after  placing  the  other 
electrode  on  any  convenient  part  of  the  body,  turning  on 
the  current.  If  the  muscle  is  in  a  healthy  condition  and 
the  current  of  moderate  strength  a  contraction  will  at  once 
occur.  This  contraction  is  tetanic  if  the  primary  current  is 
rapidly  interrupted  by  the  automatic  vibrator  common  to  all 
such  batteries.  In  testing,  however,  it  is  better  that  the 
interruptions  should  be  at  longer  intervals  so  that  single 
contractions  may  be  observed  and  a  minimum  of  discom- 
fort caused.  If  the  battery  is  not  specially  provided  with 
a  slow  interrupter  the  same  result  may  be  obtained  by  first 
starting  the  battery  and  then  turning  back  the  adjusting 
screw  of  the  vibrator  just  far  enough  to  prevent  its  working 
in  the  ordinary  way,  after  which  the  electrodes  are  to  be 
applied  and  the  vibrator  flicked  with  the  finger  so  as  to  mo- 
mentarily close  the  primary  circuit  and  immediately  open  it 
again.  Each  time  this  is  done  there  is  an  isolated  secondary 
shock  to  which  the  muscle  responds  with  a  single  contrac- 
tion. The  exact  location  of  the  motor  points  is  easily  learned 
by  practice  with  the  aid  of  the  accompanying  diagrams. 

Where  the  nerve  supplying  a  group  of  muscles  is  readily 
accessible,  for  example,  the  ulnar  where  it  passes  the  elbow 
or  the  external  popliteal  where  it  passes  around  the  head 
of  the  fibula,  the  whole  group  may  be  made  to  contract  at 
once  by  applying  the  electrode  over  the  nerve. 


EXAMINATION    OF    THE    PATIENT. 


31 


MAPS   OF  MOTOR    POINTS. 


Fig.  I. 


Frontalis 

Facial  {upper) 
Corrugator  supercilii 

Orbic.  palpebrarum 
Nasal  muscles 

Zygomatici 

Orbic.  oris. 

Facial  {middle). 

Masseter. 

Levator  menti. 

Quadratus. 

Triangularis. 

HyfioglossHs. 
Facial  {lower). 

Platysma  myoides. 
Hvoid  muscles. 


Omo-hyoid 

Extr.  anterior 

thoracic  (pectoralis 

major). 


Ascending  frontal  and 
parietal  convolutions 
(motor  area). 


3d  frontal  convolution 
and  insula  (center  of 
speech). 

Temporalis. 

Facial  {upper  branch). 
Facial  {trunk). 
Posterior  auricular. 

Facial  {middle  branch). 
Facial  {lower  brajich). 
Splenius. 
Sterno-mastoideus. 

Spinal  accessory. 
I,evatoranguli  scapulas 

Trapezius. 
Dor  sal  is  scapula 
(rhomboids). 

Circumflex. 


Long  thoracic  (serratus 
magnus). 


Motor  Points  on  Face  and  Neck. 
{From  Ormerod,  after  Erb  and  DeWatteville. 


32 


NERVOUS    AND    MENTAL    DISEASES. 
Fig.  2. 


Triceps  (long  head) 


Triceps  (inner  head) 


Ulnar. 


Flexor  carpi  ulnaris. 

Flexor  profundus 
digitorum. 


Flexor  sublimis  digit 
(II  &  III). 

Do.  do.     (index  and 
little  fingers). 

Ulna 


Palmaris  brevis 

Abductor  min.  digit 

Flexor  min.  digit 

Opponens  min.   digit 


XfUmbricales. 


Median. 
Supinator  longus. 

Pronator  teres. 


Deltoid     (ante- 
rior portion). 


Musculo- 
cutaneous. 


Biceps. 


Brachialis 

anticus 


Flexor  carpi  radialis. 

Flexor  sublimis  digitorum 

Flexor  longus  pollicis. 

Median. 

Abductor  pollicis. 
Opponens  pollicis. 

Flexor  brevis  pollicis. 

Adductor  pollicis. 


Motor  Points  on  Upper  IvImb,  Flexor  Surface. 
{Frotn  Ormerod,  after  Erb  and DeWatteville.) 


EXAMINATION    OF    THE    PATIENT. 


33 


Fig.  3. 


Deltoid  (pos- 
terior part). 


Musculo-spiral. 
Brachialis  anticus. 

Supinator  longus, 
Ext.  carpi  radial,  longior 
Ext.  carpi  radial,  brevior 


Extensor  communis  / 
digitorum.  ( 

Extensor  indicis. 

Ext.  ossis  metacarpi 

poUicis 
Ext.  prinii  internodii 
poUicis. 


Dorsal  interossei 


Triceps  (long  head). 


Triceps  (outer  head). 


Extensor  carpi  ulnaris. 
Supinator  brevis. 

Extensor  minimi  digiti. 
Extensor  indicis. 

Extensor  secundi  inter- 
nodii poUicis. 


Abductor  minimi  digit. 

Dorsal  interossei  (III  & 
IV). 


Motor  Points  on  Upper  Limb,  Extensor  Surface. 
{Frotn  Ormerod,  after  Erb  and  De  Watieville. ) 


34 


NERVOUS    AND    MENTAL    DISEASES. 


Fig.  4. 


Anterior  crural. 

Obturator. 
Pectineus. 

Adductor  niagnus. 
Adductor  longus. 

Crureus. 
Vastus  internus. 


Tensor  fasciae  femoris. 

Sartorius. 
Quadriceps  femoris. 
Rectus  femoris. 


>  Vastus  externus. 


Motor  Points  on  Thigh,  Anterior  Surface. 
(From  Ormerod,  after  Erb  and  DeWatteville.) 


EXAMINATION    OF    THE    PATIENT. 


35 


Fig.  5. 


Sciatic. 

Biceps  (longhead). 
Do.  (short  head). 


Peroneal. 


Gastrocnemius 
(outer  head). 


Soleus. 


Flexor  longus  hallucis. 


Adductor  magnus. 

Semi-tendinosus. 

Semi-membranosus. 


Posterior  tibial. 


Gastrocnemius 
(inner  head). 


Soleus. 

Flexor  longus  digitorum. 

Posterior  tibial. 


Motor  Points  on  Lower  I,imb,  Posterior  Surface. 
{From  Ormerod,  after  Erb  and  DeWatteville.) 


36 


NERVOUS    AND    MENTAL    DISEASES. 


Fig.  6. 


Tibialis  anticus.' 
Extensor  longus 
digitorutn. 


Peroneus  brevis 


Extensor  longus 
hallucis. 


Peroneal. 


Gastrocnemius. 
Peroneus  longus. 


Flexor  longus 
hallucis. 


Extensor  brevis 
digitorum. 


Abductor  minimi 
digiti. 


Motor  Points  on  I^eg,  External  Surface. 
{From  Ortnerod,  after  Erb  and  De  Watteville.) 


EXAMINATION    OF    THE    PATIENT. 


37 


Muscles  that  are  paralyzed  by  functional  disease  or  by 
organic  disease  of  the  upper  motor  segment  (that  is  of  the 

Fig.  7. 


Diagram  of  an  Element  of  the  Motor  Path.— {Tyson  af/er  Strumpell.)  C,  motor 
ganglion  cell  in  the  cerebral  cortex ;  Py  S,  lateral  pyramidal  tract,  central  or  upper 
motor  neuron  ;  V,  ganglion  cell  of  anterior  horn  ;  w,  motor  nerve,  peripheral 
neuron;  M,  muscular  fiber. 


cortical  motor  centers  or  pyramidal  tracts,  C  or  Py  S^  Fig. 
7)  retain  their  faradic  irritability  unimpaired  and,  with  very 
rare  exceptions,  they  do  not  waste.     But  muscles  paralyzed 


38  NERVOUS    AND    MENTAL    DISEASES. 

by  organic  disease  of  the  lower  motor  segment  (that  is  of 
the  anterior  horns  of  the  spinal  cord,  the  motor  nuclei  at 
the  base  of  the  brain  or  the  peripheral  nerves,  For  M^  Fig. 
7),  as  in  poliomyelitis,  bulbar  paralysis  or  neuritis,  are  in 
a  very  different  condition.  Within  about  two  weeks  of  in- 
terruption of  this  part  of  the  motor  tract  their  faradic  irrita- 
bility is  lost  or  impaired,  according  to  the  severity  of  the 
disease.  This  is  because  the  faradic  current  can  make  a 
muscle  contract  only  by  exciting  its  motor  nerve  fibers  and 
in  this  class  of  diseases  the  nerve  fibers  are  degenerated. 
This  degeneration  also  causes  the  muscles  to  waste  by  pre- 
venting them  from  receiving  the  normal  influence  of  their 
trophic  nerve  centers.  Moreover,  they  lose  their  tone  and 
their  tendon  reflexes.  When  the  faradic  irritability  of  a 
muscle  is  merely  diminished,  the  diminution  may  be  de- 
tected by  first  applying  the  current  to  the  affected  muscle 
and  then  to  another  known  to  be  healthy,  preferably  to  the 
corresponding  one  on  the  opposite  side. 

The  tests  of  the  galvanic  irritability  of  a  muscle  are  not 
so  simple  as  the  Faradic  test  because  the  positive  and  neg- 
ative electrodes  have  an  unequal  effect  on  the  muscle  and 
a  reaction  is  sometimes  caused  by  opening  as  well  as  by 
closing  the  circuit.  Only  the  most  elementary  account  of 
the  galvanic  reactions  will  be  given  here,  but  it  will  suffice 
for  practical  diagnosis. 

If  the  negative  electrode,  or  kathode,  be  placed  over  the 
middle  of  a  healthy  muscle,  the  positive  one  being  on  an}- 
convenient  part  of  the  body,  and  a  current  of  about  five 
milliamperes  gradually  turned  on,  there  will  be  no  visible 
effect.  But  if  the  current  be  interrupted  and  then  suddenly 
closed,  the  muscle  will  give  a  single  quick  contraction  at 
the  moment  of  closure.  This  is  called  the  kathodal  closure 
contraction  and  is  often  abbreviated  to  K.  C.  C.  If  the  cur- 
rent now  be  reversed  so  that  the  positive  pole,  or  anode,  is 


EXAMINATION    OF    THE    PATIENT.  39 

on  the  muscle,  and  closure  be  made  after  an  interruption, 
there  will  be  no  visible  contraction  or  a  weaker  one  than 
that  obtained  with  the  kathode :  only  by  using  a  somewhat 
stronger  current  can  the  anode  be  made  to  cause  a  contrac- 
tion equal  to  the  previously  obtained  kathodal  closure  con- 
traction. Hence  it  is  said  that  kathodal  closure  contrac- 
tion is  greater  than  anodal  closure  contraction,  or,  in 
abbreviated  form,  K.C.C>A.C.C. 

In  functional  paralysis  and  in  paralysis  due  to  organic 
disease  of  the  upper  motor  segment  the  galvanic  reactions 
of  the  muscles  remain  as  in  health.  But  in  muscles  whose 
lower  motor  segment  {V  or  Af,  Fig.  7)  is  diseased,  espe- 
cially if  the  disease  has  advanced  rapidly,  there  is  a  striking 
change.  We  have  already  seen  that  such  muscles  lose  their 
faradic  irritability.  Galvanic  irritability,  on  the  contrary,  is 
commonly  increased,  so  that  a  contraction  is  caused  by  a 
weaker  current  than  is  necessary  for  the  normal  muscle. 
This  contraction,  however,  instead  of  being  quick,  as  in  the 
normal  muscle,  is  sluggish  and  suggests  the  contraction  of  a 
worm.  Moreover,  closing  the  current  causes  a  greater  con- 
traction with  the  positive  pole  on  the  muscle  than  it  does 
with  the  negative  pole,  which  is  expressed  by  the  formula  A. 
C.  C.  >K.  C.  C,  just  the  reverse  of  that  for  the  healthy 
muscle.  These  two  peculiarities,  the  sluggishness  of  the 
contraction  and  the  excess  of  A.  C.  C.  over  K.  C.  C.  con- 
stitute the  reaction  of  degeneration,  which  is  often  abbre- 
viated to  R.  D.  The  reaction  of  degeneration  appears 
within  about  two  weeks  of  complete  and  rapid  interruption 
of  the  lower  motor  segment  and  persists  for  some  months, 
giving  way  to  the  normal  reaction  if  the  motor  tract  be  re- 
stored and  passing  into  complete  loss  of  galvanic  irritability 
if  there  be  no  restoration.  In  very  gradual  destruction  of 
the  lower  motor  segment,  as  in  the  slower  cases  of  spinal 
muscular   atrophy,  it  does  not  appear  at  all  and  there  is  a 


40  NERVOUS    AND    MENTAL    DISEASES. 

simple  loss  of  galvanic  irritability.  Muscles  showing  the 
reaction  of  degeneration  are  flabby,  have  lost  their  tendon 
reflexes  and  are  soon  conspicuously  wasted. 

THE    REFLEXES. 

All  reflex  actions  are  alike  in  that  their  occurrence  is 
proof  of  the  organic  integrity  of  the  reflex  arc,  consisting 
of  a  sensory  tract,  nerve  center  and  motor  tract.  They 
differ  greatly,  however,  in  diagnostic  import  and  are  gen- 
erally divided  into  three  classes  :  (i)  Tendon,  or  deep  re- 
flexes ;  (2)  superficial,  or  skin  reflexes,  and  (3)  visceral 
reflexes. 

A  tendon  reflex  is  the  process  by  which  a  sudden  in- 
crease in  the  tension  of  a  muscle,  usually  brought  about 
by  tapping  its  tendon,  evokes  a  muscular  contraction  in 
response. 

Of  all  the  tendon  reflexes  the  knee-jerk  is  by  far  the 
most  important  and  its  utilization  in  diagnosis  was  one  of 
the  great  achievements  of  modern  neurology.  It  tells  so 
much  and  tells  it  so  quickly  that  every  one  who  practices 
medicine  should  use  it  as  habitually  as  he  does  percussion 
or  auscultation. 

The  knee-jerk  is  usually  elicited  by  having  the  patient 
sit  with  one  knee  crossed  over  the  other  and  then  striking 
a  recoiling  blow  upon  the  patellar  tendon  with  the  ends  of 
the  fingers.  In  ordinary  cases  the  foot  will  promptly  be 
jerked  forward  by  a  contraction  of  the  quadriceps  exten- 
sor muscle.  If  the  patient  is  in  bed  the  test  may  readily 
be  made,  without  disturbing  him,  by  raising  the  knee  so 
that  the  leg  and  thigh  form  an  angle  a  little  greater  than  a 
right  angle,  the  foot  resting  easily  on  the  bed,  and  then 
striking  the  tendon.  In  this  case  the  foot  may  not  move, 
unless  the  reflex  is  exaggerated,  but  the  contraction  of  the 
quadriceps  is  easily  seen  or  felt. 


EXAMINATION    OF    THE    PATIENT. 


41 


After  some  practice  the  examiner  can  tell  at  once  whether 
the  knee-jerk  is  normal,  exaggerated  or  diminished,  espe- 
cially if  the  responses  on  the  two  sides  are  carefully  com- 
pared. In  exaggeration  not  only  is  the  range  of  motion 
increased,  but  a  response  is  evoked  by  a  lighter  blow  on 
the  tendon  than  is  necessary  in  normal  cases.  When  the 
response  is  slight  it  may  be  made  more  distinct  by  Jendras- 
sik's  method  of  reinforcement,  which  consists  in  having 
the  patient  make  some  effort  with  the  upper  part  of  the 
body,  such  as  pulling  on  his  clasped  hands  or  pressing  the 
examiner's  hand,  at  the  moment  the  tendon  is  struck.  The 
eyes  should  be  closed  at  the  same  time. 

If  the  knee-jerk  is  not  elicited  by  the  tests  so  far  described 
it  is  not  to  be  regarded  as  absent  until  further  trials  show 
that  it  can  not  be  elicited  by  any  means  whatever.  Perfect 
relaxation  of  all  the  muscles  of  the  knee  is  essential  in  all 
doubtful  cases  and  the  examiner  should  not  only  tell  the 
patient  to  relax  and  let  the  leg  hang  limp,  but  he  should 
feel  of  the  flexor  tendons  and  quadriceps  to  be  sure  that 
they  are  lax.  Having  the  patient  sit  on  the  edge  of  a  table 
with  the  legs  hanging  free  may  be  necessary  to  secure  full 
relaxation.  A  single  distinct  response  is  to  be  taken  as 
outweighing  all  previous  failures.  But  if  relaxation  has 
been  secured  and  reinforcement  employed  and  striking  the 
tendon  still  evokes  no  response,  especially  if  tests  have 
been  made  on  different  days,  the  very  significant  note  is  to 
be  made  that  the  knee-jerk  is  absent. 

The  reflex  arc  for  the  knee-jerk  consists  of  sensory  fibers 
of  the  anterior  crural  nerve  passing  from  the  quadriceps  ex- 
tensor muscle  to  the  second,  third  and  fourth  lumbar  seg- 
ments of  the  spinal  cord,  of  these  segments  themselves  and 
of  the  motor  fibers  passing  from  them  back  to  the  muscle. 
Organic  disease  interrupting  this  arc  at  an}^  point  must  ob- 
viously prevent  the  occurrence  of  the  reflex  and,  for  some 
4 


4^ 


NERVOUS    AND    MENTAL    DISEASES. 


unexplained  reason,  traumatic  destruction  of  a  dorsal  or 
cervical  segment  of  the  cord  also  abolishes  it,  although  less 
severe  injury  or  disease  in  the  dorsal  or  cervical  part  of  the 
cord  exaggerates  it.  Accordingly  we  find  the  knee-jerk  to 
be  absent  in  all  organic  diseases  of  the  anterior  crural 
nerve,  of  the  corresponding  nerve  roots  or  of  the  second, 
third  and  fourth  lumbar  segments  of  the  cord  (such  as 
tabes,  neuritis,  poliomyelitis  and  myelitis)  and  also  in  the 
severer  cases  of  fracture-dislocation  of  the  spine.  Con- 
versely, the  persistent  absence  of  knee-jerk  is  proof  of  some 
such  organic  disease. 

Exaggeration  of  the  knee-jerk  occurs  in  all  organic  dis- 
eases which  impair  the  integrity  of  the  upper  (cortical) 
motor  segment  for  the  quadriceps  extensor,  provided  the 
reflex  arc  is  intact,  or  that  only  a  moderate  proportion  of 
its  motor  or  sensory  neurons  is  degenerated,  and  that  com- 
plete destruction  of  any  cervical  or  dorsal  segment  of  the 
cord  has  not  occurred.  Such  diseases  are  vascular  lesions, 
inflammations  and  degenerations  in  the  brain,  cervical  or 
dorsal  myelitis,  lateral  sclerosis,  postero-lateral  sclerosis 
and  amyotrophic  lateral  sclerosis.  They  cause  exaggera- 
tion of  the  knee-jerk  and  other  tendon  reflexes  by  inter- 
rupting the  normal  cerebral  control  over  the  spinal  centers 
and,  in  proportion  to  the  degree  of  interruption,  the  exag- 
geration may  be  slight  or  very  great.  In  the  latter  case  if 
the  patella  is  grasped  and  quickly  pulled  downward  a  series 
of  rapidly  recurring  contractions,  constituting  patellar  clo- 
nus, may  occur.  In  hysteria,  neurasthenia  and  other  func- 
tional diseases  the  knee-jerk  is  often  exaggerated  but  not 
to  the  degree  which  is  common  in  organic  disease.  Very 
great  exaggeration,  therefore,  especially  if  accompanied 
by  ankle  clonus,  is  to  be  taken  as  presumptive  proof  of 
organic  disease  but  moderate  exaggeration  may  be  due  to 
either  organic  or  functional  disease. 


EXAMINATION    OF    THE    PATIENT.  43 

The  presence  of  knee-jerks  that  are  equal  on  the  two 
sides  and  normal  also  has  great  significance  ;  their  pres- 
ence and  equality  exclude  any  disease  seriously  affecting 
either  of  the  reflex  arcs  and  the  absence  of  exaggeration 
excludes  any  disease  of  the  brain  or  spine  involving  the 
upper  motor  segment. 

What  the  knee-jerk  tells  may  be  summed  up  thus  : 

1.  Its  absence  is  evidence  either  of  organic  disease  of 
some  part  of  the  reflex  arc  or  of  complete  destruction  of 
a  cross-section  of  the  cord. 

2.  Its  great  exaggeration  along  with  ankle  clonus  is 
proof  of  organic  disease  affecting  the  upper  motor  segment 
for  the  leg,  but  its  moderate  exaggeration  may  be  due  to 
either  functional  or  organic  disease. 

3.  Its  presence  in  normal  and  equal  degree  on  the  two 
sides  is  proof  of  the  absence  of  any  organic  disease  of  the 
reflex  arc  and  of  any  organic  disease  of  the  brain  or  cord 
affecting  the  upper  motor  segment  for  extension  of  the 
knee. 

The  Achilles  tendon  reflex,  or  heel-jerk  is  elicited  by 
supporting  the  foot  lightly,  the  knee  being  slightly  flexed, 
and,  after  seeing  that  the  limb  is  passive,  striking  the  tendon 
a  recoiling  blow  with  the  ends  of  the  fingers.  Ordinarily 
the  blow  is  followed  in  about  a  tenth  of  a  second  by  a  con- 
traction of  the  calf  muscles  and  a  corresponding  movement 
of  the  foot.  This  movement  is  normally  much  less  con- 
spicuous than  the  knee-jerk  but  it  may  be  much  exagger- 
ated in  disease.  When  thus  exaggerated  a  form  of  the 
reflex  called  ankle  clonus  may  be  produced  by  supporting 
the  leg  with  the  knee  slightly  flexed  and,  after  securing 
relaxation,  making  an  abrupt  but  not  too  forcible  attempt 
to  passively  flex  the  foot.  The  sudden  tension  of  the  calf 
muscles  causes  a  reflex  contraction  and,  if  pressure  is  main- 
tained on  the  sole  of  the  foot,  the   tension  is  instantly  re- 


44 


NERVOUS    AND    MENTAL    DISEASES. 


newed  so  that  a  series  of  contractions  occurs,  making  the 
foot  vibrate  at  the  rate  of  five  to  nine  times  a  second.  In 
typical  ankle  clonus  this  vibration  continues  for  a  con- 
siderable time  if  the  proper  degree  of  pressure  is  main- 
tained. Ankle  clonus  may  also  be  elicited  by  having  the 
patient  sit  with  the  toe  resting  lightly  on  the  floor,  the  heel 
being  an  inch  or  two  above  it,  and  then  smartly  pressing 
the  knee  downward  so  as  to  flex  the  foot.  In  some  con- 
ditions clonus  also  appears  when  the  patient  attempts  to 
walk. 

The  reflex  arc  for  the  heel-jerk  consists  of  the  fifth  lum- 
bar and  first  sacral  segments  of  the  cord  together  with 
sensory  and  motor  fibers  of  the  spinal  cord  connecting  them 
with  the  calf  muscles.  The  presence  of  heel-jerks  that  are 
normal  and  equal  on  the  two  sides  excludes  organic  disease 
(such  as  neuritis,  tabes  and  myelitis)  affecting  the  reflex 
arc  at  any  point  and  also  organic  disease  of  the  brain  or 
upper  part  of  the  cord  affecting  the  upper  motor  segment 
for  the  calf  muscles.  The  absence  of  the  reflex,  on  the 
other  hand,  is  not  to  be  taken  as  proof  of  disease  unless 
corroborated  by  other  signs.  When  exaggeration  is  so 
great  that  typical  ankle  clonus  can  be  elicited  organic  dis- 
ease of  the  upper  motor  segment  certainly  exists ;  the 
spurious  clonus  occasionally  seen  in  severe  hysteria  has  a 
slower  rate,  and  generally  ceases  after  a  few  vibrations. 
Moderate  exaggeration,  however,  is  often  seen  in  func- 
tional as  well  as  in  organic  disease. 

Although  the  knee-jerk  and  heel-jerk  are  by  far  the  most 
important  tendon  reflexes,  there  are  others  which  should  al- 
ways be  tested  when  disease  of  the  corresponding  sensory  or 
motor  tracts  is  in  question.  In  the  upper  limb  reflex  muscu- 
lar contractions  may  often  be  evoked  by  tapping  the  tendons 
of  the  pectoralis  major,  triceps,  biceps  or  any  of  the  muscles 
moving  the  wrist  or  fingers.     The  limb  should  be  passive 


EXAMINATION    OF    THE    PATIENT.  45 

in  such  a  posture  that  the  muscle  to  be  tested  is  but  shghtly 
stretched.  The  centers  for  these  reflexes  are  at  various 
levels  from  the  fifth  to  the  eighth  cervical  segments.  Under 
any  conditions  the  presence  of  a  reflex  is  proof  of  the  in- 
tegrity of  its  reflex  arc.  If  a  muscle  is  paralyzed  absence 
of  the  tendon  reflex,  except  in  rare  cases  of  hysteria,  is 
proof  of  lesion  of  the  lower  motor  segment,  that  is  of  the 
cord  or  nerves,  while  great  exaggeration  is  proof  of  organic 
lesion  in  the  upper  motor  segment.  Moderate  exaggeration 
may  be  a  symptom  of  either  organic  or  functional  disease. 
Absence  of  the  reflex  in  a  muscle  otherwise  normal  has 
no  positive  significance. 

A  tendon  reflex  of  the  muscles  of  mastication,  which 
has  received  the  uneuphonious  name  of  jaw-jerk,  may 
sometimes  be  elicited  by  downward  tapping  on  the  half- 
dropped  lower  jaw.  When  exaggerated  it  indicates  dis- 
ease of  the  upper  motor  segment  for  the  muscles  of 
mastication. 

The  superficial  reflexes  are  muscular  contractions  caused 
by  irritation  of  the  skin  or  mucous  membrane.  The  most 
important  of  these  are  the  plantar,  gluteal,  cremasteric, 
lower  abdominal,  epigastric,  palmar  and  scapular,  hav- 
ing their  centers  at  various  levels  of  the  spinal  cord, 
and  the  conjunctival,  having  its  center  at  the  base  of  the 
brain. 

The  plantar  reflex  is  elicited  by  scratching  or  tickling 
the  sole  of  the  foot,  and  consists  first  of  a  movement  of  the 
toes,  if  the  irritation  is  slight,  followed,  if  the  irritation  is 
stronger,  by  flexion  of  the  hip,  knee  and  ankle  so  as  to 
withdraw  the  foot.  Its  center  is  in  the  first  three  sacral 
segments.  It  has  recently  been  proved  that  except  in  in- 
fancy the  normal  response  of  the  toes  is  flexion  and  that  if 
their  first  movement,  particularly  that  of  the  great  toe,  is 
extension,  without  dorsal  flexion  of  the  foot,  a  lesion  of 


46  NERVOUS    AND    MENTAL    DISEASES. 

the  upper  motor  segment  for  the  foot  is  almost  always 
present. 

The  gluteal  reflex  is  a  contraction  of  the  gluteal  muscles 
in  response  to  an  irritation  of  the  skin  of  the  buttock.  Its 
center  is  in  the  fourth  and  fifth  lumbar  and  first  sacral 
segments. 

The  cremasteric  reflex  is  a  contraction  of  the  cremas- 
ter  muscle,  drawing  the  testicle  upward,  caused  by  irri- 
tating the  skin  on  the  inside  of  the  thigh.  Its  center  is  in 
the  first  three  lumbar  segments. 

The  lower  abdominal  reflex  is  a  contraction  of  the  ab- 
dominal muscles  in  response  to  an  irritation  of  the  skin  in 
the  iliac  region.  Its  center  is  in  the  lower  five  dorsal  and 
first  lumbar  segments.  The  epigastric,  or  upper  abdominal 
reflex  is  a  dimpling  of  the  epigastrium  in  response  to  an 
irritation  of  the  skin  over  the  lower  anterior  margin  of  the 
chest  and  has  its  center  in  the  fourth  to  seventh  dorsal  seg- 
ments. 

The  palmar  reflex  is  a  flexion  of  the  fingers  caused  by 
irritating  the  palm.  It  is  generally  absent  except  in  young 
children  and  has  its  center  in  the  lower  two  cervical  and 
first  dorsal  segments.  The  scapular  reflex  is  a  contraction 
of  the  supraspinati  and  infraspinati  muscles  in  response  to 
an  irritation  of  the  skin  over  them.  Its  center  is  in  the 
lower  four  cervical  segments.  The  conjunctival  reflex  is 
the  well-known  closure  of  the  eyelids  caused  by  irritation 
of  the  conjunctiva.     Its  center  is  in  the  pons. 

In  testing  the  superficial  reflexes  it  is  best  to  make  the 
irritation  of  the  skin  rather  sharp  so  as  to  get  a  response  at 
the  outset,  as  the  reflex  irritability  is  rapidly  dulled  by  the 
repetition  of  gradually  increasing  irritations. 

The  importance  of  the  superficial  reflexes  consists  in 
their  presence  being  proof  of  the  integrity  of  the  respective 
reflex  arcs ;  the  exaggeration  or  absence  of  most  of  them 


EXAMINATION    OF    THE    PATIENT.  47 

is  of  little  significance  because  it  may  be  caused  by  many 
trivial  variations  from  health  as  well  as  by  severe  ones. 

The  visceral  reflexes  to  be  kept  in  mind  in  a  neurolog- 
ical examination  are  the  palatal,  pharyngeal  and  laryngeal 
and  the  anal  and  vesical.  The  three  first  named  may  be 
elicited  in  health  by  touching  the  respective  parts  with  a 
feather  or  probe  but  are  absent  or  diminished  in  bulbar 
paralysis,  diphtheritic  paralysis  and  some  cases  of  hysteria. 
The  anal  and  vesical  reflexes  are,  of  course,  always  nor- 
mal when  micturition  and  defecation  are  normally  per- 
formed ;  they  are  abolished  by  disease  of  the  third  and 
fourth  sacral  segments  or  the  corresponding  nerves,  in 
which  case  there  will  be  inability  to  retain  urine  or  feces 
and  digital  examination  will  find  the  sphincter  ani  loose 
and  flabby  instead  of  contracting  on  the  finger ;  these  re- 
flexes, although  not  lost,  are  disturbed  by  disease  of  the 
cord  above  the  centers  and  by  bilateral  brain  disease, 
in  which  case  there  is  both  retention  and  incontinence  of 
urine  and  feces,  that  is  inability  to  secure  voluntary  evac- 
uations and  inability  to  place  restraint  upon  involuntary 
ones,  but  the  sphincter  ani  is  firm  and  contracts  on  the  ex- 
amining finger. 

Taking  the  reflexes  as  a  whole,  it  will  be  seen  that  they 
furnish  a  means  of  testing  an  extensive  series  of  reflex 
arcs  whose  centers  form  an  almost  unbroken  line  reaching 
from  the  lower  sacral  segments  through  the  entire  cord 
into  the  medulla  and  pons.  As  it  is  highly  improbable,  in 
any  organic  disease  of  the  nerves,  cord  or  brain,  that  all 
the  reflexes  should  remain  normal,  their  presence  in  a 
normal  degree  is  often  a  strong  reassurance  when  organic 
disease  has  been  feared,  and  in  medico-legal  cases  it  may 
disprove  the  claim  of  an  hysterical,  neurasthenic  or  maling- 
ering plaintiff  that  he  is  suffering  from  an  irreparable 
injury. 


48  NERVOUS    AND    MENTAL    DISEASES. 

TESTS    OF    CUTANEOUS    SENSIBILITY. 

The  sensibility  of  the  skin  to  touch,  pain  and  temperature 
may  demand  careful  investigation  in  certain  cases.  In 
making  the  tests  the  patient  is  blindfolded  or  required  to 
keep  the  eyes  closed.  Sensibility  to  touch  is  tested  by 
lightly  touching  various  points  with  a  camel's  hair  pencil, 
a  bit  of  absorbent  cotton  or  the  end  of  the  finger  and 
noting  whether  the  patient  feels  the  touch  and  can  locate  it 
accurately.  To  test  pain  the  quill  end  of  the  pencil  may 
be  sharpened  or  the  point  of  a  pin  used  to  prick  the  skin ; 
when  the  pain  sense  is  defective  pricking  the  skin  gives 
an  impression  of  touch  instead  of  a  sharp  sting.  The 
temperature  sense  is  tested  by  applying  bottles  or  test- 
tubes,  one  filled  with  warm  and  the  other  with  cool  water, 
the  temperatures  being  such  as  to  cause  a  distinct  feeling 
of  warmth  or  coolness  to  the  normal  skin. 

These  tests  are  quite  decisive  and  easily  made  when  the 
cutaneous  sensibility  is  normal  or  is  greatly  impaired,  but 
when  the  defect  is  slight  the  investigation  is  tedious  and 
perplexing.  In  such  a  case  it  is  important  to  compare  the 
surface  whose  sensibility  seems  to  be  diminished  with  a 
part  known  to  be  normal,  especially  with  the  correspond- 
ing part  on  the  opposite  side  of  the  body,  and  for  a  delicate 
test  the  two  parts  should  be  touched  or  pricked  at  the  same 
time.  In  all  cases  in  which  sensory  loss  is  an  important 
factor  in  diagnosis  the  limits  of  the  insensitive  area  should 
be  carefully  marked  on  the  body  and  then  transferred  to 
a  diagram  so  as  to  determine  as  accurately  as  possible 
whether  it  corresponds  to  the  area  of  one  or  more  nerves  or 
spinal  segments  or  merely  to  the  external  configuration  of 
some  part  of  the  body  or  to  a  geometric  area.  (Figs.  8  to 
II,  28  and  29.) 


EXAMINATION    OF    THE    PATIENT. 


49 


Fig.  8. 


Circumflex. 


Musctilo-spiral  (external 
spiral  branch). 


Musculo-cntaneous. 


Median. 


Cervical  plexus 

(descending  branches). 


Intercosto-hunieral. 


Lesser  internal  cutaneous 
(nerve  of  Wrisberg). 


Internal  cutaneous. 


Ulnar. 


Diagram  of  Cutaneous  Nerve-Supply  of  Upper  t,iMB. 

{Frotn'.Ormerod,  after  Flower.) 

Anterior  Surface. 


50 


NERVOUS    AND    MENTAL    DISEASES. 


Fig.  9. 


Intercosto-hunieral. 


Lesser  internal  cutaneous 
(nerve  of  Wrisberg). 


Internal  cutaneous. 


Ulnar. 


Cervical  plexus 

(descending  branches). 


Circumflex. 


Internal  cutaneous  branch. 
Kxternal  cutaneous 
branch  of  musculo-spiral. 


Musculo-cutaneous 


Radial. 


Posterior  Surface.     {From  Ormerod  ) 


EXAMINATION    OF    THE    PATIENT. 


51 


Fig.  10. 


Genito-crural. 


Kxterual  cutaneous. 


Patellar  plexus. 


External  or  short  saphe- 
nous. 


-     Ilio-inguinal. 


Ilio-hypogastric. 
Pudic. 


Middle  cutaneous  branch. 


Internal  cutaneous  branch 
of  anterior  crural. 


Internal  or  long  saphenous 
from  anterior  crural. 


Musculo-cutaneous 

branch. 
Anterior  tibial  branch  of 


peroneal. 


Diagram  of  the  Cutaneous  Nerve-Supply  of  the  I,ower  I,imb. 

{From  Ormerod,  after  Flower.) 

Anterior  Surface. 


52 


NERVOUS    AND    MENTAL    DISEASES. 


Fig.  II. 


l/Umbar  and  sacral. 


Pudic  and  small  sciatic. 


Small  sciatic. 


Internal  cutaneous  branch 
of  anterior  crural. 


Internal  or  long  saphe- 
nous. 


Posterior  tibial. 


Ilio-iusruinal. 


External  cutaneous. 


External  or  short  saphe- 
nous. 


Diagram  of  the  Cutaneous  Nerve-Sopply  of  the  Lower  Limb. 

{From  Onnerod,  after  Flower.) 

Posterior  Surface. 


EXAMINATION    OF    THE    PATIENT.  53 

THE    POSTURE    SENSE. 

The  recognition  of  the  posture  of  different  parts  of  the 
body,  without  the  aid  of  sight  or  touch,  depends  mainly  on 
muscular  sense,  but  is  aided  by  the  sensibility  of  the 
various  parts  of  a  joint  and  of  the  skin  over  it.  It  is  tested 
by  having  the  patient's  eyes  closed  and  then  firmly  grasp- 
ing the  parts  on  one  or  both  sides  of  a  joint  and  putting  it 
in  different  postures,  telling  the  patient  to  imitate  each 
posture  with  the  opposite  limb  or  to  tell  what  is  being  done. 

TASTE    AND    SMELL. 

For  testing  taste  one  should  have  on  hand  solutions  of 
sugar,  common  salt,  citric  acid  and  quinine,  to  be  used  in 
the  order  named.  The  tongue  is  protruded  and  held  by 
the  examiner  while  some  of  the  solution  on  a  brush  or 
wisp  of  cotton  is  gently  rubbed  in  on  either  side.  The 
patient  should  nod  assent  or  dissent  to  the  examiner's 
questions  without  having  the  tongue  released.  Some- 
times, however,  the  taste  is  not  perceived  until  the  tongue 
is  replaced,  when  it  immediately  becomes  quite  distinct. 
This  as  a  rule  has  no  clinical  significance. 

Smell  can  easily  be  tested  by  dropping  some  perfume 
of  any  kind  on  a  little  cotton  and  holding  it  to  either 
nostril. 

EXAMINATION    OF    THE    EAR. 

Inspection  of  the  external  ear  may  reveal  anomalies  of 
form  indicating  deg'^neration  and  predisposition  to  neurotic 
affections. 

Hearing  is  most  easily  tested  by  holding  the  watch  op- 
posite either  ear  and  noting  the  maximum  distance  at 
which  it  can  be  heard.  This  distance  is  to  be  put  down  as 
the  numerator  of  a  fraction  of  which  the  normal  distance 
is  the  denominator ;  thus  if  the  watch  is  heard  at  20  inches 


54  NERVOUS    AND    MENTAL    DISEASES. 

and  no  farther,  and  the  normal  ear  hears  it  at  30  inches, 
hearing  is  recorded  as  20/30. 

If  the  watch  shows  deafness  on  one  side  the  next  ques- 
tion is  whether  it  is  due  to  disease  of  the  external  or  middle 
ear  or  to  disease  of  the  internal  ear,  auditory  nerve  or 
brain.  This  question  can  be  answered,  aside  from  in- 
spection of  the  external  auditory  canal  and  tympanic  mem- 
brane, by  placing  the  handle  of  a  vibrating  tuning  fork  on 
the  top  of  the  head  or  on  the  upper  teeth  and  noting  in 
which  ear  the  sound  seems  louder.  If  it  is  louder  in  the 
deaf  ear  then  bone  conduction  is  not  impaired  and  the  dis- 
ease is  in  the  external  or  middle  ear  and  has  no  significance 
from  the  strictly  neurological  point  of  view.  But  if  it  is 
louder  in  the  sound  ear  bone  conduction  is  impaired  in  the 
deaf  one  so  the  disease  must  be  in  the  inner  ear,  auditory 
nerve  or  brain  and  the  defect  is  called  nervous  deafness. 

The  result  of  this  test  may  be  confirmed  by  comparing 
the  patient's  bone  conduction  with  the  examiner's  in  the 
following  way :  The  tuning  fork  while  vibrating  strongly 
enough  for  the  patient  to  distinctly  hear  it  by  bone  conduc- 
tion is  pressed  on  the  temporal  bone  just  above  and  behind 
the  ear.  The  sound  gradually  becomes  fainter  and  the 
patient  makes  a  signal  as  soon  as  he  no  longer  hears  it. 
The  examiner  then  immediately  transfers  the  fork  to  the 
same  position  on  his  own  head  and  if  he  still  hears  it  the 
patient's  bone  conduction  is  impaired  and  the  deafness  is 
nervous.  This  method  is  especially  valuable  when  hear- 
ing is  impaired  on  both  sides. 

In  certain  cases  of  nervous  deafness  it  may  be  important 
to  determine  the  limits  of  the  auditor}^  field  for  high  notes 
by  means  of  Galton's  whistle. 

EXAMINATION    OF    THE    EYE. 

A  mere  inspection  of  the  eyes  will  often  reveal  impor- 


EXAMINATION    OF    THE    PATIENT.  55 

tant  symptoms,  such  as  drooping  of  the  upper  lid,  protru- 
sion of  the  ball,  difference  in  the  pupils,  strabismus  and 
nystagmus. 

Proceeding  to  a  more  minute  examination,  the  pupils 
should  be  compared  with  each  other  when  exposed  to  light 
and  again  when  shaded.  Then  each  pupil  should  be 
tested  for  light  reaction  while  the  other  eye  is  closed,  the 
patient  looking  at  some  distant  object  so  as  to  eliminate  the 
effect  of  accommodation.  In  health  each  pupil  contracts 
when  a  near  object  is  looked  at.  This  is  called  the  reac- 
tion to  accommodation,  or  convergence,  and  is  tested  by 
observing  the  pupils  while  the  patient  looks  first  at  a  dis- 
tant object  and  then  at  the  point  of  a  pencil  close  at  hand, 
the  line  of  vision  remaining  the  same  so  as  to  exclude 
variations  in  the  light. 

Inequality  of  pupils  without  loss  of  light  reaction  may 
be  due  to  so  many  conditions  of  the  eye,  of  the  nervous 
system  and  even  of  other  organs,  that  it  has  no  definite 
significance  when  considered  alone.  But  when  it  appears 
in  addition  to  cerebral  symptoms,  such  as  headache,  vomit- 
ing and  disturbance  of  consciousness,  and  cannot  be  ac- 
counted for  by  disease  of  the  eye  or  of  the  chest  or  neck, 
it  is  strongly  indicative  of  organic  cerebral  disease.  Ab- 
sence of  light  reaction,  if  not  caused  by  a  drug  or  by 
disease  within  the  orbit,  is  proof  of  cerebral  or  cerebro- 
spinal disease,  which  is  almost  invariably  organic.  Ab- 
sence of  light  reaction  together  with  preservation  of  reaction 
to  accommodation  constitutes  the  Argyll-Robertson  pupil, 
a  sure  sign  of  degenerative  disease  of  the  central  nervous 
system,  often  seen  in  tabes  and  sometimes  in  paretic  de- 
mentia. 

A  general  idea  of  the  condition  of  the  motor  apparatus 
of  the  eyes  may  be  obtained  by  observing  them  while  the 
patient  looks  to  the  right  and  left,  upward,  downward  and 


56  NERVOUS    AND    MENTAL    DISEASES. 

obliquely.  Nystagmus,  a  tremulous  or  jerky  oscillation  of 
the  eyeball,  may  be  apparent  in  the  extreme  positions 
although  entirely  absent  when  the  eyes  look  straight  ahead. 

Paralysis  of  the  ocular  muscles  is  of  the  greatest  sig- 
nificance and  must  be  looked  for  whenever  organic  disease 
within  the  cranium  is  suspected.  Paralysis  of  the  levator 
palpebral  is  easily  recognized  as  it  causes  ptosis,  or  droop- 
ing of  the  upper  lid,  which  can  be  due  to  no  other  cause 
except  spasm  of  the  orbicularis.  This  spasm  is  rare  and 
can  readily  be  distinguished  as  an  active  resistance  to  the 
separation  of  the  lids  which  causes  fine,  concentric  wrinkles 
in  the  skin  over  them. 

Paralysis  of  any  of  the  external  muscles  of  the  eyeball 
is  indicated  by  four  symptoms  :  (i)  Displacement  of  the 
eye  at  rest  in  a  direction  opposite  to  that  in  which  the 
paralyzed  muscle  should  move  it;  e.  g.,  in  paralysis  of 
the  external  rectus  the  eye  is  turned  inward.  (2)  Limita- 
tion of  movement  in  the  direction  in  which  the  affected 
muscle  acts;  e.  g.,  in  complete  paralysis  of  the  external 
rectus  the  eye  cannot  be  moved  outward  beyond  the  mid- 
position.  (3)  Diplopia,  the  image  of  the  affected  eye,  called 
the  false  image,  being  displaced  in  the  direction  in  which 
the  paralyzed  muscle  should  turn  the  eye  ;  when  the  posi- 
tion of  the  object  requires  an  effort  to  look  in  this  direction 
the  two  images  are  farthest  apart,  but  when  the  object  is 
carried  to  the  opposite  side,  so  that  no  effort  is  required  of 
the  paralyzed  muscle,  the  two  images  come  together  ;  e.g., 
in  paralysis  of  the  right  external  rectus  the  image  seen 
by  the  right  eye  (false  image)  is  displaced  to  the  right  of 
the  true  one  when  the  object  is  directly  in  front  of  the 
patient;  when  it  is  carried  to  the  patient's  right  the  images 
separate  still  farther  but  when  it  is  carried  to  his  left  they 
come  together  again.  In  paralysis  of  the  right  internal 
rectus  the  false  image  is  displaced  to  the  left  of  the  true 


EXAMINATION    OF    THE    PATIENT.  57 

one,  the  two  images  coming  together  when  the  object  is 
taken  to  the  patient's  right.  It  will  be  noticed  that  the  di- 
plopia is  crossed  (image  of  right  eye  to  left  and  vice  versa) 
when  the  axes  of  vision  diverge  and  that  it  is  homonymous 
(image  of  right  eye  to  right  and  left  to  left)  when  the  axes 
of  vision  are  crossed. 

4.  Secondary  deviation  of  the  sound  eye  :  When  an  at- 
tempt is  made  to  look  at  an  object  in  the  direction  in  which 
the  paralyzed  muscle  should  move  the  eye,  the  sound  eye, 
if  covered,  will  move  too  far  in  this  direction,  but  will 
immediately  move  back  to  its  proper  position  when  un- 
covered. 

The  displacement  of  the  eye  at  rest  and  the  limitation  of 
movement  are  readily  observed  by  the  examiner  except 
when  the  paralysis  is  slight  or  affects  one  of  the  oblique 
muscles  alone.  It  must  be  remembered,  however,  that  in 
coma  and  even  in  deep  sleep  the  eyes  may  diverge  and  be 
turned  upward  and  yet  be  perfectly  normal  when  con- 
sciousness returns. 

To  study  the  diplopia  let  the  patient  look  at  a  candle  or 
a  vertical  strip  of  white  paper  and,  in  order  to  distinguish 
the  two  images,  place  a  colored  glass  before  one  eye,  pre- 
ferably the  sound  one.  If  both  images  are  not  readily 
seen  or  if  no  colored  glass  is  at  hand,  have  the  patient 
close  first  one  eye  and  then  the  other,  carefully  noting  the 
apparent  change  in  the  position  of  the  object. 

To  test  for  secondary  deviation  hold  a  card  between  the 
sound  eye  and  the  point  of  a  pencil  held  in  such  a  position 
that  to  fix  it  with  the  affected  eye  the  muscle  in  question 
must  act.  Then  if  the  sound  eye  moves  too  far  it  can  be 
observed  and  on  quickly  removing  the  card  it  will  be  seen 
to  move  back  to  its  proper  position. 

The  following  table  gives  a  condensed  description  of  the 
signs  of  paralysis  of  each  of  the  individual  muscles  : 
5 


58 


NERVOUS    AND    MENTAL    DISEASES. 


TABLE    OF    SIGNS    OF    PARALYSIS    OF    EXTERNAL 
OCULAR    MUSCLES. 


Displacement        Limitation 
Muscle.          of  visual  axis,     ofmovem^ent. 

Position  of  false 
image. 

Secondary 
deviation  of 
sound  eye. 

External 
Rectus. 

Inward. 

Outward. 

To  the  side  of 
affected  eve. 

Inward. 

Internal 
Rectus. 

Outward. 

Inward. 

To  the  side  oppo- 
site that 
of  affected  eye. 

Outward. 

Superior 
Rectus. 

Downward. 

Upward. 

Above  and  to  side 

opposite  that 

of  affected  eye. 

Upward. 

Inferior 
Rectus. 

Upward. 

Downward. 

Below  and  to  side 

opposite  that 

of  affected  eye. 

Downward. 

Superior 
Oblique. 

Difficult  to 
detect. 

Difficult  to 
detect. 

Below-  and  to  side 

of  affected  eve. 

Image  tilted,  top 

inward. 

Downward 
and  inward. 

Inferior 
Oblique. 

Difficult  to 
detect. 

Difficult  to 
detect. 

Above  and  to  side 

of  affected  eye. 

Image  tilted,  top 

outward. 

Upward 
and  inward. 

The  two  internal  muscles  of  the  eye,  the  sphincter  of 
the  iris  and  the  muscle  of  accommodation  are  also  liable 
to  paralysis,  which  is  indicated  by  dilatation  of  the  pupil 
and  loss  of  light  reaction  and  reaction  to  accommodation  in 
the  case  of  the  sphincter  and  by  inability  to  focus  the  eye 
on  near  objects  when  the  muscle  of  accommodation  is 
paralyzed. 

Individual  ocular  muscles  may  be  paralyzed  alone  or  in 
combination  with  others,  according  to  the  seat  and  extent 
of  the  disease.  Such  a  paralysis  is  one  of  the  strongest 
proofs  of  organic  disease  of  the  nervous  system  ;  it  may 
in  rare  cases  be  due  to  toxic  influences  without  organic 
change  or  to  a  functional  neurosis  like  migraine  or  epi- 
lepsy but  it  is  practically  unknown  in  hysteria. 


EXAMINATION    OF    THE    PATIENT.  59 

The  external  rectus  is  frequently  paralyzed  alone,  being 
the  only  muscle  supplied  by  the  sixth  nerve,  which  from 
its  long  course  is  especially  exposed  to  danger  in  disease 
at  the  base  of  the  brain.  Isolated  paralysis  of  the  superior 
oblique  is  also  not  rare  because  it  is  the  only  muscle  sup- 
plied by  the  fourth  nerve.  Either  of  these  muscles  may 
also  be  paralyzed  by  disease  of  the  corresponding  nucleus. 
All  the  other  ocular  muscles,  external  and  internal,  are 
supplied  by  the  third  nerve  and,  in  a  lesion  of  the  nerve 
trunk,  generally  suffer  together,  so  that  the  eye  is  turned 
outward,  motion  is  limited  inward,  upward  and  downward, 
the  lid  droops,  the  pupil  is  dilated,  accommodation  is  lost 
and  there  is  crossed  diplopia.  When  only  a  part  of  the 
muscles  supplied  by  the  third  nerve  are  paralyzed  the  dis- 
ease is  more  commonly  in  the  nuclei  beneath  the  aqueduct 
of  Sylvius,  but  it  may  possibly  be  limited  to  the  corre- 
sponding branches  of  the  nerve. 

So  far  paralysis  of  individual  muscles  or  muscle  groups 
has  been  spoken  of.  But  there  is  another  form  in  which 
the  muscles,  tested  separately,  give  no  characteristic  sign 
of  paralysis  or  even  act  normally,  while  there  is  distinct 
loss  of  power  to  perform  one  or  more  of  the  associated 
movements  of  both  eyes  :  viz.,  convergence,  divergence, 
looking  to  either  side  or  upward  or  downward.  As  these 
associated  movements  are  normally  under  voluntary  con- 
trol, it  will  readily  be  understood  that  they  may  be 
lost,  as  a  result  of  suggestion  in  hysteria.  They  may 
also  be  lost  in  organic  central  disease,  particularly  of  the 
cortex. 

Spasm  of  ocular  muscles,  especially  of  the  internal  recti, 
may  occur  and  may  be  mistaken  for  paralysis  of  the  op- 
ponents. In  spasm  the  limitation  of  movement,  especially 
if  the  eyes  be  separately  tested,  is  less  marked  and  less 
constant,  the  double  images  do  not  separate  on  looking  in 


6o  NERVOUS    AND    MENTAL    DISEASES. 

one  direction  to  come  together  again  on  looking  the  oppo- 
site way  and  there  is  no  secondary  deviation. 

Lack  of  proper  balance  of  the  muscles  moving  the  eyes, 
not  sutHcient  ordinarily  to  cause  diplopia,  may  be  of  con- 
siderable importance  in  hysteria  and  neurasthenia,  al- 
though the  reports  of  remarkable  cures  from  the  correction 
of  such  a  defect  alone  are  to  be  received  with  much  allow- 
ance for  the  patient's  susceptibility  to  suggestion.  The 
balance  of  the  internal  and  external  recti  when  the  eyes 
are  at  rest  can  be  tested  by  placing  a  prism  of  eight  or  ten 
degrees,  with  its  base  downward  and  accurately  horizontal, 
in  the  trial  frame  before  one  eye,  and  then  having  the 
patient  look  at  a  candle  or  a  vertical  strip  of  paper  or  a 
horizontal  scale  at  the  other  side  of  the  room.  The  prism 
causes  vertical  diplopia  and  if  the  muscle  balance  is  nor- 
mal the  upper  image  will  be  exactly  above  the  lower  or 
(on  account  of  the  slight  convergence  necessary  in  looking 
at  an  object  only  a  few  yards  distant)  very  slightly  dis- 
placed to  the  side  opposite  the  prism.  If  the  upper  image 
is  displaced  a  few  inches  or  more  to  the  side  opposite  the 
prism  then  there  is  a  relative  insufficiency  of  the  internal 
recti.  If  the  upper  image  is  displaced  to  the  same  side  as 
the  prism  there  is  a  relative  insufficiency  of  the  external 
recti.  The  balance  of  the  muscles  which  turn  the  eye  up- 
ward and  downward  may  similarly  be  tested  by  placing  a 
prism  of  about  ten  degrees  with  its  base  inward  and  ac- 
curately vertical  before  one  eye.  If  the  double  images  of 
the  test  object  are  in  the  same  horizontal  plane  the  balance 
is  normal.  If  the  image  of  one  eye  is  above  that  of  the 
other  and  the  vertical  distance  between  them  increases  as 
the  object  is  raised,  the  superior  rectus  of  that  eye  is  rela- 
tively weak.  The  converse,  of  course,  indicates  weakness 
of  the  inferior  rectus. 

The  relative  power  of    the    muscles   in  action  may  be 


EXAMINATION    OF    THE    PATIENT.       .  6l 

measured  by  finding  the  strongest  prism  that  may  be 
placed  before  one  eye  and  still  permit  the  two  images  of 
the  object  to  be  fused  into  one.  The  internal  recti  should 
be  able  thus  to  fuse  the  two  images  with  a  prism  of  about 
thirty  degrees  placed  before  either  eye,  base  outward. 
The  external  recti  are  much  weaker,  but  should  overcome 
a  prism  of  about  eight  degrees,  base  inward.  The  su- 
perior and  inferior  recti  should  overcome  a  prism  of  about 
three  degrees,  base  upward  or  downward.  These  figures 
are  to  be  taken  as  merely  approximate  and  considerable 
allowance  is  to  be  made  for  individual  variations  within 
physiologic  limits,  especially  when  there  are  no  symptoms 
attributable  to  muscular  strain. 

Acuity  of  vision  for  distant  objects  is  tested  in  each  eye 
separately  by  having  the  patient  read  the  smallest  letters 
possible  for  him  on  a  well-lighted  test  card  across  the 
room.  The  result  is  expressed  by  a  fraction  of  which  the 
distance  of  the  card  is  the  numerator  and  the  distance  at 
which  the  same  letters  can  be  read  by  a  normal  eye  the 
denominator.  Thus  if  the  smallest  letters  read  at  20  feet 
are  read  by  the  normal  eye  at  50  feet  the  vision  is  recorded 
as  20/50.  Acuity  for  near  objects  and  the  range  of  ac- 
commodation can  be  measured  together  by  finding  the 
smallest  type  that  the  patient  can  read  and  the  limits 
within  which  it  is  read. 

When  acuity  of  vision  is  impaired  we  must  find  whether 
the  defect  is  due  to  an  error  of  refraction,  to  disease 
of  the  media  or  to  disease  of  the  retina,  optic  nerve  or 
brain.  Any  defect  that  can  be  fully  corrected  by  a  spher- 
ical convex  lens  is  due  to  either  hypermetropia  or  presbyo- 
pia. A  defect  which  is  limited  to  distant  vision  and  can  be 
fully  corrected  by  a  concave  spherical  lens  is  due  to 
myopia.  A  defect  which  is  different  in  degree  for  lines  at 
the  same  distance,  running  in  different  directions,  and  can 


62  NERVOUS    AND    MENTAL    DISEASES. 

be  corrected  only  by  the  use  of  a  cylindrical  lens,  with  or 
without  a  spherical  one  in  combination,  is  due  to  astigma- 
tism. Disease  of  the  media,  retina  or  head  of  the  optic 
nerve  will  be  visible  on  ophthalmoscopic  examination. 
Retrobulbar  disease  of  the  nerve  or  disease  of  the  brain  is 
to  be  inferred  from  the  exclusion  of  other  causes  and  the 
combination  of  symptoms  present. 

The  fields  of  vision  are  of  great  importance  in  neuro- 
logical diagnosis.  To  test  them  one  eye  should  be  cov- 
ered and  the  other  kept  fixed  on  a  small  object  straight 
ahead.  Then  a  piece  of  white  paper,  two-fifths  of  an 
inch  square,  is  brought  forward  on  the  outer  side  of  the 
eye  until  it  is  just  visible,  which  should  be  when  a  line 
from  the  paper  to  the  eye.  makes  an  angle  of  about  90° 
with  the  line  of  direct  vision.  The  paper  is  next  brought 
forward  on  the  nasal  side  until  just  visible,  which  should 
be  at  an  angle  of  about  55°.  When  brought  into  view  from 
above,  it  should  be  visible  at  about  50°,  and  from  below 
at  about  70°. 

As  the  paper  is  brought  in  from  the  point  at  which  it 
first  becomes  visible  toward  the  line  of  fixation  it  should 
grow  more  and  more  distinct,  except  when  it  passes 
through  the  normal  blind  spot,  whose  center  is  about  13° 
to  the  outer  side  of  the  point  of  fixation.  If  it  disappears 
in  any  other  part  of  the  field  or  grows  indistinct  the  defect 
is  called  a  scotoma. 

After  testing  the  fields  for  white,  colored  papers  of  the 
same  size  should  be  used,  noting  the  greatest  distance  from 
the  point  of  fixation  at  which  the  color  can  be  recognized. 
Of  the  three  colors  most  employed,  blue  has  the  largest 
field,  red  the  next  and  green  the  smallest.  The  color 
fields  may  be  defective  in  spots  although  no  corresponding 
defect  for  white  may  exist ;  such  spots  are  called  color 
scotomata. 


EXAMINATION    OF    THE    PATIENT.  63 

The  foregoing  rough  method  will  suffice  for  ordinary 
cases,  especially  if  it  indicates  a  normal  condition  of  the 
fields,  but  much  more  accurate  results  can  be  obtained  by 
mapping  them  by  the  aid  of  some  form  of  perimeter,  as 
described  in  the  text-books  of  ophthalmology. 

The  defects  in  the  fields  that  are  of  most  importance 
from  the  neurological  point  of  view  are  hemianopia,  or 
blindness  in  one  half  of  the  field,  concentric  limitation,  or 
blindness  in  a  peripheral  zone,  scotomata,  or  blindness  in 
isolated  spots,  and  reversal  of  the  normal  relations  of  the 
color  fields,  e.  g.,  that  for  green  being  larger  than  that 
for  red. 

Hemianopia  is  generally  bilateral  and  homonymous,  that 
is,  both  fields  are  affected  and  the  right  or  left  half  of  each 
is  blind.  In  such  a  case  the  patient  looking  directly  at  any 
object  with  both  eyes  open  sees  only  the  right  or  left  half 
of  it.  This  symptom  is  conclusive  proof  of  organic  in- 
tracranial disease  except  when  it  is  part  of  an  attack  of 
migraine  and  in  extremely  rare  cases  where  an  hys- 
terical patient  may  have  become  so  familiar  with  it  as 
to  make  its  acquirement  by  suggestion  possible.  The 
lesion  may  be  in  the  optic  tract,  in  the  region  of  the  an- 
terior corpus  quadrigeminum,  in  the  optic  radiation  or  in 
the  cortex  about  the  calcarine  fissure  ;  it  is  always  on  the 
side  of  the  brain  opposite  the  blind  side  of  the  fields. 
Peripheral  limitation  of  the  field  occurs  in  hysteria,  in 
which  it  is  usually  regular,  and  in  atrophy  of  the  optic 
nerve,  in  which  it  is  apt  to  be  irregular.  Scotomata  occur 
in  diseases  of  the  retina  and  of  the  optic  nerve.  Reversal 
of  the  normal  relation  of  the  color  fields  is  generally 
believed  to  occur  only  in  hysteria. 

Skill  in  the  use  of  the  ophthalmoscope  is  of  the  greatest 
importance  to  the  neurologist  unless  he  can  constantly 
command  the   services   of  an  ophthalmologist,  which,  of 


64  NERVOUS    AND    MENTAL    DISEASES. 

course,  is  seldom  practicable.  It  should  by  all  means  be 
acquired  through  personal  instruction  but  it  is  possible  for 
the  persevering  to  acquire  it  alone.  For  directions  as  to 
practice  the  reader  is  referred  to  any  good  text-book  of 
ophthalmology.  The  student  of  neurology  should  espe- 
cially practice  the  direct  method  and  first  learn  to  recognize 
the  normal  appearance  of  the  disk  and  the  changes  caused 
in  it  by  optic  neuritis  and  optic  atrophy.  (Figs.  21  to  24.) 
He  should  then  become  familiar  with  the  appearance  of" 
the  various  forms  of  retinitis  and  choroiditis.  The  colored 
lithographs,  commonly  furnished  in  the  atlases  and  text- 
books, are  invaluable  for  the  student  who  cannot  have 
personal  instruction  in  a  large  clinic. 

EXAMINATION    AS    TO    SPEECH. 

The  various  ways  of  using  language  are  functions  of  a 
complicated  nervous  mechanism,  easily  deranged  by  dis- 
ease, and  the  consequent  defects  are  not  only  of  great 
interest  psychologically  but  are  of  great  practical  impor- 
tance in  diagnosis.  In  conducting  the  examination  four 
lines  of  inquiry  should  be  followed  in  regular  order. 

I.  The  patient's  talk.  Are  words  badly  uttered ?  If  so, 
is  the  defect  due  to  spasmodic  arrest  of  utterance  or  to  the 
omission,  replacement  or  wrong  arrangement  of  difficult 
sounds?  Are  the  intonation  and  accent  normal  to  the 
patient?  Entirely  distinct  from  the  mode  of  utterance  is 
the  question  whether  the  words  used  (considering  the 
patient's  age  and  education)  are  sufficient  in  number,  ap- 
propriate and  properly  arranged.  Is  the  stock  of  words 
used  very  small?  Is  the  same  expression  used  over  and 
over  without  regard  to  meaning?  Are  wrong  words  simi- 
lar in  sound  or  associated  in  meaning  substituted  for  the 
right  ones  ?  Are  correct  and  incorrect  words  mingled  in 
a  confused  jargon?     Can  he  name  familiar  objects?     Can 


EXAMINATION    OF    THE    PATIENT,  65 

he  repeat  the  words  he  hears?     If  he  does  not  talk  at  all 
may  it  be  due  to  mental  disease? 

2.  The  comprehension  of  oral  speech.  Do  the  patient's 
answers  to  questions  show  that  he  understands  them?  Can 
he  be  made  to  comply  with  simple  but  unexpected  re- 
quests, such  as  to  raise  the  right  hand  or  close  the  left 
eye,  made  in  an  ordinary  tone,  without  gesture  or  change 
of  facial  expression?  Can  he  select  familiar  objects  when 
named?  If  comprehension  is  defective  can  it  be  explained 
by  ordinary  deafness? 

3.  The  ability  to  read.  Does  the  patient  occupy  him- 
self with  books  and  papers  as  he  formerly  did?  Can  he 
read  aloud?  Can  he  show  that  he  comprehends  what  he 
reads  ?  Does  he  compl}'  with  written  requests  to  perform 
simple  actions?  Can  he  read  and  understand  figures? 
Does  he  comprehend  the  nature  of  ordinary  objects  when 
he  sees  them  ?  If  there  is  any  defect  is*  it  explained  by 
simple  loss  of  vision? 

4.  The  ability  to  write.  Can  the  patient  write  his  signa- 
ture? Are  the  letters  properly  formed  or  is  there  tremor 
or  incoordination?  Can  he  express  himself  in  writing? 
Can  he  write  from  dictation?  Can  he  copy?  Can  he 
write  figures  and  perform  arithmetical  operations?  Can 
he  make  even  the  crudest  drawings  of  familiar  objects? 
If  there  is  any  defect  is  it  due  to  paralysis,  and  if  he  can- 
not write  with  the  right  hand  can  he  with  the  left,  or  can 
he  trace  words  with  the  foot? 

EXAMINATION    AS    TO    THE    MENTAL    CONDITION. 

Before  examining  a  person  supposed  to  be  insane,  the 
family  and  personal  history  should,  whenever  possible,  be 
obtained  from  a  relative  or  friend,  paying  special  attention 
to  nervous  or  mental  disease  in  other  members  of  the 
family,  to  any  change  in  the  character  of  the  patient  and 
G 


66  NERVOUS    AND    MENTAL    DISEASES. 

the  time  at  which  the  change  began,  and  to  any  facts  indi- 
cating failure  of  memory,  depression,  exaltation,  halluci- 
nations or  delusions.  Except  in  the  rarest  cases,  where 
danger  of  violence  or  of  obstinate  refusal  to  be  examined 
makes  deception  necessarj^,  the  physician  should  appear 
in  his  true  character,  but  he  should  treat  the  patient  as 
though  sane  and  should  examine  as  though  looking  for 
some  purely  physical  ailment. 

The  usual  questions  as  to  age,  place  of  residence,  occu- 
pation, domestic  relations,  previous  illnesses  and  present 
sufferings  should  be  asked ;  the  answers  may  not  be  re- 
liable, but  they  are  valuable  as  indications  of  the  state  of 
memory  and  the  general  mental  condition.  Sleep  and 
dreams  are  important  in  themselves  and  as  affording  an 
easy  and  natural  transition  to  hallucinations. 

The  questions  are  to  be  followed  by  a  thorough  physical 
examination  of  the  nervous  system  and  the  most  important 
organs,  for  much  depends  on  the  recognition  or  exclusion 
of  organic  nervous  disease,  infectious  diseases  and  intoxi- 
cations. Special  attention  is  to  be  paid  to  the  condition  of 
the  pupils,  tremor,  twitching  of  the  face,  articulation,  pulse, 
temperature  and  the  urine.  Incidentally  the  physical  ex- 
amination will  very  probably  cause  the  patient  to  reveal 
some  of  his  mental  peculiarities. 

Proceeding  to  the  psychological  problems  of  the  case, 
the  patient  is  to  be  led  into  conversation  about  himself.  If 
he  talks  freely  it  is  seldom  difficult  to  recognize  the  emo- 
tional exaltation  and  rapid  flow  of  ideas  characteristic  of 
mania,  the  hopeless  depression  and  slow  ideation  of 
melancholia  or  the  weakened  judgment  and  loss  of 
memory  indicative  of  dementia.  Delirium  (with  its  lack  of 
consciousness  of  the  present  surroundings  and  incoherent 
hallucinations)  and  mere  stupor  are  as  a  rule  not  hard  to 
distinguish  from  the  types  of  mental  disease  just  men- 
tioned, but  transition  forms  may  be  perplexing. 


EXAMINATION    OF    THE    PATIENT.  67 

The  symptoms  of  paranoia  are  sometimes  very  difficult 
to  detect.  Hallucinations  are  to  be  inquired  for,  when 
suspected,  as  though  they  were  ordinary  symptoms,  but 
with  as  smooth  a  transition  as  possible  ;  thus  if  the  patient 
is  annoyed  by  steam  whistles  it  is  easy  to  ask  whether  the 
noise  ever  seems  to  take  the  form  of  words,  then  what  the 
words  are  and  what  motive  anyone  could  have  for  saying 
such  things.  Or,  if  there  are  unpleasant  dreams,  it  is 
natural  to  ask  what  is  seen  in  the  dreams  and  then 
whether  such  things  ever  appear  during  the  waking  mo- 
ments. If  delusions  are  suspected  but  not  revealed  the 
conversation  should  be  made  to  turn  indirectly  upon  re- 
ligion, politics,  inventions,  electricity  or  persecutions, 
according  to  the  history  previously  obtained,  and  this  will 
generally  succeed.  If  a  delusion  be  revealed  the  next 
question  is  whether  it  is  systematized,  that  is,  whether  the 
patient  can  give  logically  connected  reasons,  however  ab- 
surd they  may  be,  for  his  belief. 

Sometimes,  especially  if  a  reliable  history  has  not  been 
obtained,  all  our  efforts  will  elicit  nothing  decisive.  The 
patient  answers  quietly  and  naturally,  showing  no  undue 
emotion  and  no  defect  of  judgment  or  memory,  and  be- 
traying no  hallucinations  or  delusions.  Such  a  person  is 
either  sane  or  a  paranoiac  who  is  skillfully  concealing  his 
delusions  and  it  is  generally  better  to  postpone  the  exam- 
ination to  another  time  than  to  prolong  it  unduly  and  to 
seem  too  anxious  to  find  out  the  patient's  secret.  In  the 
meantime  inquiries  can  be  made  and  the  best  method  of 
leading  up  to  the  probable  delusion  considered. 

If  the  patient  will  not  talk  at  all  attention  to  his  attitude 
and  expression  will  almost  always  discover  the  reason.  A 
dull,  vacant  or  silly  expression  indicates  idiocy,  dementia 
or  stupor.  A  sad  or  anxious  look  with  an  attitude  of  pro- 
found dejection  indicates  that  speech  is  inhibited  by  mel- 


68  NERVOUS    AND    MENTAL    DISEASES. 

ancholia.  A  rapt,  ecstatic  or  keen  and  vigilant  look,  with 
an  attitude  of  alertness,  betrays  the  paranoiac  who  has  a 
command  from  heaven  not  to  talk  or  a  delusion  that  talk- 
ing will  give  his  persecutors  an  advantage  over  him. 

Cases  of  delirium  or  stupor,  in  which  the  patient  is 
manifestly  insane  for  the  time  being,  but  which  are  not 
typical  of  mania,  melancholia,  dementia  or  paranoia,  can- 
not be  elucidated  by  psychological  methods  alone.  On 
the  contrary,  the  results  of  the  entire  examination  are  to 
be  considered  in  an  effort  to  recognize  the  physical  disorder 
of  which  the  mental  disturbance  is  but  one  symptom. 
Here,  as  in  many  other  parts  of  the  field  of  neurology  and 
psychiatry,  is  an  illustration  of  the  fact  that  no  one  can  be 
a  competent  neurologist  or  alienist  without  first  being  a 
competent  general  physician. 


THE    RECOGNITION    OF    ORGANIC    DISEASE.  69 


THE    RECOGNITION    OF    ORGANIC 
DISEASE. 

For  clinical  purposes  all  nervous  disorders  are  divided 
into  two  classes,  organic  diseases,  whose  symptoms  are 
caused  by  a  visible  alteration  in  the  structure  of  the  ner- 
vous system,  and  functional  diseases,  in  which  impaired 
nutrition  of  the  neurons  is  assumed  but  in  which  the  most 
refined  methods  of  investigation  fail  to  reveal  visible 
structural  changes.  This  is  a  somewhat  crude  division, 
but  it  has  been  of  the  greatest  practical  advantage  and 
in  the  present  state  of  knowledge  is  of  fundamental 
importance. 

It  is  generally  necessary,  before  proceeding  to  the  more 
special  diagnosis  to  answer  the  general  question  whether 
the  disease  is  organic  or  functional  or  a  mixture  of  both. 
This  question  is  often  the  most  difficult  one  connected  with 
the  case  and,  as  an  incorrect  answer  is  likely  to  lead  to  a 
useless  or  even  disastrous  plan  of  treatment,  the  symptom.s 
which  may  be  decisive  are  worthy  of  the  most  careful 
study.  The  presence  or  absence  of  signs  indicating  or- 
ganic disease  must  alone  be  considered  at  first.  Until  this 
is  done  symptoms  of  functional  disorder,  however  charac- 
teristic, should  be  allowed  no  weight,  for  hysteria  or  neu- 
rasthenia may  complicate  the  gravest  organic  conditions. 
The  significance  of  many  of  the  signs  of  structural 
change  has  already  been  mentioned  in  discussing  the  ex- 
amination of  the  patient,  but  it  is  desirable  to  consider 
them  together. 


70  NERVOUS    AND    MENTAL    DISEASES. 

Paralysis  of  external  ocular  muscles  not  due  to  local 
conditions  within  the  orbit,  unless  limited  to  the  conjugate 
motions  of  both  eyes  which  one  may  voluntarily  make  or 
refrain  from  making,  is  almost  absolute  proof  of  organic 
disease  within  the  cranium  ;  the  exceptions  are  certain  ex- 
tremely rare  cases  of  migraine,  epilepsy  or  toxemia.  With 
the  same  qualifications  failure  of  light  reaction  is  equally 
significant,  provided  the  influence  of  such  drugs  as  atro- 
pine or  physostigmin  can  be  excluded.  Mere  inequality 
of  pupils  is  not  quite  so  important,  but  if  it  is  known  to 
have  occurred  during  the  progress  of  the  disease  in  ques- 
tion and  is  not  due  to  peripheral  irritation  on  the  side  of 
the  dilated  pupil  it  is  almost  as  conclusive.  The  Argyll- 
Robertson  pupil  is  invariably  due  to  degeneration  of  the 
central  nervous  system.  Optic  neuritis  or  optic  atrophy  is 
in  itself  organic  nervous  disease,  and  in  connection  with 
cerebral  symptoms  is  proof  of  intracranial  organic  change, 
provided  we  can  exclude  certain  forms  of  intoxication, 
particularly  uremia,  alcoholism,  plumbism  and  tobacco 
poisoning.  Well-defined  and  persistent  hemianopia  is  al- 
ways organic.  As  a  transient  symptom  it  may  occur  in 
migraine. 

Paralysis  of  the  face  is  practically  always  organic  un- 
less, as  may  rarely  happen,  it  is  caused  by  uremia.^ 
Paralysis  of  the  palate,  except  when  a  part  of  adynamic 
bulbar  paralysis,  is  organic.  It  is  especially  significant  as 
one  of  the  earliest  symptoms  of  an  oncoming  diphtheritic 
paralysis.  Paralysis  of  laryngeal  muscles  if  bilateral  may 
be  either  organic  or  functional,  but  if  unilateral  it  is  al- 
ways organic.     Loss  of  control  of  the  bladder  and  rectum 


'  Genuine  cases  of  hysterical  facial  paralysis  are  so  excessively  rare  that 
their  possible  occurrence  may  be  disregarded  in  ordinary  diagnosis. 
Glosso-labial  spasm  is  more  frequent. 


THE    RECOGNITION    OF    ORGANIC    DISEASE.  7 1 

is  generally  organic,  and  paralysis  of  the  sphincters  is 
alwa3's  so. 

The  mowing  gait  or  steppage  gait  is  proof  of  organic 
paralysis.  Paralysis,  with  or  without  corresponding  sen- 
sory loss,  which  is  definitely  limited  to  the  muscles  supplied 
by  nerve  trunks  or  spinal  segments  is  organic. 

Atrophy  of  muscles  with  loss  of  faradic  irritabilit}^  is 
due  either  to  organic  nervous  disease  or  to  idiopathic  dis- 
ease of  the  muscles.  Reaction  of  degeneration  or  tibrilla- 
tion  in  a  wasted  muscle  proves  the  existence  of  organic 
disease  of  the  lower  motor  segment. 

Genuine  absence  of  knee-jerk  is  almost,  but  not  quite 
absolute  proof  of  organic  disease  of  the  nervous  system 
or  muscle.  It  is  never  a  symptom  of  hysteria  or  neuras- 
thenia, but  may  with  extreme  rarity  be  found  in  apparent 
health  and  it  has  been  successfully  simulated.  Ankle 
clonus  which  persists  for  a  considerable  time  and  has  a 
steady  rate  of  five  to  seven  vibrations  per  second  is  prob- 
ably always  organic.  A  clonus  of  very  brief  duration  or  a 
persistent  one  at  an  inconstant  rate  of  two  to  four  vibra- 
tions per  second  certainly  may  be  hysterical.  A  spastic 
condition  of  the  lower  limbs,  so  extreme  that  when  the 
examiner  lifts  one  leg  from  the  bed  the  pelvis  and  the  other 
leg  move  with  it,  is  always  organic.  The  allied  condition, 
called  spinal  epilepsy,  in  which  a  paroxysm  of  tonic 
spasm  of  the  legs  passes  into  clonic  spasm,  is  also  invari- 
ably organic.  Localized  convulsions  of  the  Jacksonian 
type  are  proof  of  a  correspondingly  localized  irritation  of 
the  cortex  which  is  almost  always  caused  by  organic  dis- 
ease. A  localized  sensory  aura  is  generally  caused  in  the 
same  way  but  there  is  a  greater  possibility  of  its  being 
merely  functional. 

If  no  evidence  of  organic  disease  is  found  it  is  still  not 
to  be  positively  excluded,  especially  if  the  symptoms  are 


72  NERVOUS    AND    MENTAL    DISEASES. 

equivocal,  until  the  time  has  elapsed  in  which  organic 
change  would  necessarily  reveal  itself.  Thus,  if  a  deli- 
cate and  possibly  tubercular  child  has  suffered  for  a  week 
from  headache,  with  occasional  vomiting,  the  absence  of 
all  signs  characteristic  of  organic  disease  requires  the 
diagnosis  of  meningitis  to  be  withheld,  but  does  not  ex- 
clude it,  for  within  the  next  few  days,  pupillary  changes, 
strabismus  or  some  other  conclusive  symptom  may  appear. 
In  the  meantime  the  special  diagnosis  that  would  follow  in 
either  case  must  be  considered  in  the  light  of  all  the  facts 
already  known.  Conversely,  the  longer  a  disease  has 
lasted  without  proof  of  its  organic  nature  the  greater  the  as- 
surance that  it  is  only  functional.  If  a  partial  hemiplegia 
has  lasted  for  months  without  such  proof,  and  the  gait  and 
other  symptoms  are  characteristic  of  hysteria,  organic 
disease  may  almost  certainly  be  excluded.^ 

It  will  probably  be  inferred  from  the  foregoing  state- 
ments that  the  recognition  or  exclusion  of  organic  disease 
in  general  is  sometimes  very  difficult  or  even,  for  the  time 
being,  impossible  ;  in  fact  it  is  generally  this  part  of  the 
diagnosis  which  calls  for  the  greatest  caution  and  the 
highest  skill  in  weighing  evidence. 

The  organic  nervous  diseases  are  divided  into  four 
groups  :  vascular  lesions,  including  hemorrhage,  embolism 
and  thrombosis,  inflammations,  effects  of  pressvire  and 
morbid  growths,  and  degenerations.  These  groups  are 
clinically  distinguished  mainly  by  the  time  of  onset,  that 
is,  the  time  that  elapses  between  the  appearance  of  the 
first  symptoms  and  their  attaining  a  considerable  degree  of 
intensity.  The  following  table,  from  Gowers,  shows  the 
relation  between  the  time  of  onset  and  the  nature  of  the 
disease. 

^  Even  then  disseminated  sclerosis  might  possibly  underlie  the 
hysteria. 


THE    RECOGNITION    OF    ORGANIC    DISEASE. 


73 


Disease 


Pressure  and 
growths 


Onset 
Sudden 
(few  minutes) 

Acute 

(few  hours  or  days) 

Subacute 

(one  to  six  weeks) 

Subchronic 

(six  weeks  to  six  months) 

Chronic 
t-  (more  than  six  months) 


Disease 


Vascular  lesions 


Inflammation 


Degeneration 


From  this  table  it  will  be  seen  that,  excepting  injuries 
and  merely  functional  disorders,  a  sudden  onset  always 
denotes  a  vascular  lesion,  as  in  a  case  of  apoplexy.  An 
acute  onset  is  most  frequently  due  to  an  inflammation,  but 
it  may  be  caused  by  a  slowly  developing  vascular  lesion, 
especially  thrombosis  or  hemorrhage.  A  subacute  onset 
denotes  inflammation  or  the  effect  of  pressure  or  morbid 
growth ;  it  is  too  slow  for  a  vascular  lesion  and  too  rapid 
for  a  degeneration.  A  subchronic  onset  denotes  chronic 
inflammation,  the  effect  of  pressure  or  growth,  or  degener- 
ation. A  chronic  onset  denotes  pressure  or  growth  or  a 
degeneration ;  it  is  too  slow  for  even  a  chronic  inflamma- 
tion. 

The  pathological  diagnosis  is  carried  still  further  by  a 
consideration  of  the  causes  of  disease  that  may  be  found, 
the  indications  afforded  by  the  accompanying  symptoms 
and  the  seat  of  the  disease,  as  shown  by  the  localizing 
symptoms.  These  indications  are  applied  in  the  tables 
which  form  the  main  portion  of  the  book. 


74  NERVOUS    AND    MENTAL    DISEASES. 


THE   PRINCIPLES    OF    LOCALIZATION. 

It  has  already  been  said  that  the  kind  of  organic  disease 
is  to  be  inferred  mainly  from  the  time  of  onset ;  the  seat  of 
the  disease  is  to  be  inferred  from  the  part  of  the  body  whose 
function  is  disturbed  and  the  character  of  the  disturbance. 
If  the  hand  is  paralyzed  it  is  known  that  the  disease  at- 
tacks some  part  of  the  motor  tract  for  the  hand,  either  the 
cortical  center,  the  pyramidal  fibers  connecting  it  with  the 
gray  matter  of  the  cervical  enlargement  of  the  cord,  this 
part  of  the  cord  itself  or  the  nerves  connecting  it  with  the 
muscles.  A  complete  knowledge  of  localization  would 
require  a  correspondingly  complete  knowledge  of  the 
anatomy  and  physiology  of  the  nervous  system  in  relation 
to  all  the  rest  of  the  body. 

In  applying  this  knowledge  to  clinical  localization  it  is 
necessary  to  distinguish  the  comparatively  limited  symp- 
toms caused  by  overaction  or  loss  of  function  at  the  seat  of 
the  lesion  alone  from  the  more  widespread  disturbance 
which  may  be  caused  by  pressure  or  shock  transmitted  to 
adjacent  and  even  distant  parts  of  the  nervous  system. 
Only  the  direct  symptoms  are  available  for  a  precise 
localization,  although  the  indirect  ones  are  important  as  a 
general  indication. 

This  distinction  is  made  by  comparing  the  extent  of  the 
symptoms  at  different  times.  Thus,  a  hemorrhage  limited 
to  the  cortical  center  for  the  right  arm,  at  first  not  only 
causes  spasm  and  paralysis  of  the  arm,  but,  by  pressure 
and  shock  affecting  the  entire  left  hemisphere,  it  may 
cause  complete  hemiplegia,  aphasia  and  unconsciousness. 


THE    PRINCIPLES    OF    LOCALIZATION. 


75 


Fig.  12. 


A  Dra"w-ing  of  the  Left  Cerebral  Hemisphere  (Human). 
Showing  the  different  localizable  areas  on  the  external  surface.    {From  Gordinier. ) 


P"lG.    13. 


A  Drawing  op  the  Right  Cerebral  Hemisphere  (Human). 
Showing  localizable  areas  on  the  median  surface.     {From  Gordinier  ) 


76 


NERVOUS    AND    MENTAL    DISEASES. 


Horizontal  I,.  F,  of  S.    j^ 


6.  Crossed   paralysis  ~ 
of  tongue   and  limbs  ; 
bulbar  palsy. 


r-$|'^ 


THE    PRINCIPLES    OF    LOCALIZATION.  77 

After  a  few  days,  however,  consciousness  and  speech  will 
have  returned,  the  paralysis  of  the  face  and  leg  will  have 
disappeared  and  only  the  paralysis  of  the  arm  will  remain 
as  a  precise  indication  of  the  seat  of  the  lesion.  Hence, 
when  the  s^'mptoms  are  of  sudden  onset,  the  later  and 
more  permanent  condition  is  the  one  on  which  to  base  the 
localization.  But,  conversely,  a  rapidly  increasing  lesion, 
say  a  tumor,  in  the  region  of  the  cortical  center  for  the 
right  arm,  may  at  first  cause  a  spasm  of  the  arm  which 
precisely  indicates  the  seat  of  disease  ;  later,  although  the 
growth  still  occupies  but  a  small  part  of  the  left  hemi- 
sphere, its  pressure  and  irritation  may  be  transmitted  to 
the  entire  brain,  causing  hemiplegia,  aphasia,  general 
convulsions  and  coma.  Hence,  in  the  case  of  a  gradually 
increasing  lesion  the  earlier  S3^mptoms  are  the  ones  avail- 
able for  localization.  It  will  be  noticed  that  while  the  im- 
portant symptoms  in  one  case  are  the  late  ones  and  in  the 
other  the  early  ones  the  time  for  localization  in  both  cases 
is  when  the  symptoms  are  most  limited  in  extent. 

The  problem  of  localization  may  be  very  much  confused 
by  the  existence  of  two  or  more  lesions.  The  only  way 
to  solve  it  is  to  be  thoroughly  familiar  with  the  effect  of 
each.     Multiple  lesions  are  mostly  syphilitic  or  tubercular. 


78  NERVOUS    AND    MENTAL    DISEASES. 


THE  SIGNS  OF  HYSTERIA. 

Hysteria  is  a  diseased  condition  in  which  perverted  ideas 
and  emotions  cause  the  bodily  symptoms.  In  its  milder 
and  more  familiar  forms  its  mental  origin  and  true  nature 
are  generally  obvious,  but  it  has  a  great  variety  of  rarer 
and  more  severe  manifestations,  which,  on  account  of 
their  close  superficial  resemblance  to  other  diseases,  often 
lead  to  the  most  serious  errors  of  diagnosis.  Any  part  of 
the  bod}^  whatever,  may  be  affected  in  severe  hysteria, 
hence,  although  it  is  a  purely  nervous  disease,  ever}^ 
practitioner  of  medicine  or  surgery  must  deal  with  it,  and 
failure  to  recognize  it  often  leads  to  treatment  that  is  un- 
necessary and  even  disastrous. 

A  trustworthy  diagnosis  of  hysteria  must  depend  first 
on  the  absence  of  the  symptoms  that  would  prove  the  ex- 
istence of  any  organic  or  other  functional  disease.  The 
signs  of  organic  disease  in  general  have  already  been  dis- 
cussed ;  the  special  form  which  is  most  likely  to  be  mis- 
taken for  hysteria  is  disseminated  sclerosis.  The  func- 
tional disorders  which  it  is  most  important  to  exclude  are 
epilepsy,  migraine,  chorea  and  various  effects  of  uremia. 
The  positive  indications  of  hysteria  are  of  the  most  varied 
character  and  may  appear,  often  quite  unexpectedly,  at 
any  point  in  the  history  or  physical  examination. 

The  family  history  is  often  doubly  significant,  for  the 
example  of  an  hysterical  mother  or  sister  may  greatly  in- 
crease whatever  predisposition  is  inherited.  The  history 
of  the  patient's  past  illnesses  may  give  strong  evidence  of 
the  abnormal  susceptibility  to  emotional  disturbances  and 


THE    SIGNS    OF    HYSTERIA.  79 

to  suggestion  which  is  the  primary  cause  of  hysteria.  It 
must  be  remembered,  however,  that  every  one  is  more  or 
less  susceptible  to  disturbing  emotions  and  ideas  ;  it  is  only 
morbid  susceptibility  that  is  to  be  taken  into  account. 

The  history  of  the  patient's  mental  experiences  imme- 
diately preceding  the  onset  is  of  great  importance.  If  the 
symptoms  closely  follow  a  strong  emotion,  or  the  observa- 
tion of  similar  symptoms  in  others  or  anxious  thought 
about  disease,  they  are  probably  hysterical.  This  is  only 
a  probability,  however,  until  other  than  mental  causes 
have  been  excluded  by  a  careful  consideration  of  the  age, 
previous  illnesses  and  present  condition  ;  for  the  onset  of 
an  organic  paraplegia  may  possibly  coincide  with  the 
shock  of  bad  news,  the  monoplegia  or  partial  hemiplegia 
that  follows  an  apparently  trivial  injury  is  sometimes  due 
to  meningeal  hemorrhage  or  syphilitic  thrombosis,  a  con- 
vulsion following  excitement  may  be  epileptic  or  toxic,  the 
palpitation  that  follows  a  talk  about  heart-disease  may  be 
primarily  due  to  a  valvular  lesion,  the  chorea  that  seems 
to  be  an  imitation  is  sometimes  genuine,  and  so  on. 

The  character  of  the  paroxysms  of  which  the  patient 
complains  often  affords  conclusive  evidence  of  hysteria. 
Fits  of  laughing  or  sobbing  and  globus  (the  feeling  of  some- 
thing rising  into  the  throat  like  that  which  precedes  sobbing) 
when  they  follow  trivial  causes,  are  proof  of  hysteria. 
Convulsions  in  which  consciousness  is  partially  retained 
and  words  are  uttered,  or  in  which  the  movements  and  at- 
titudes express  purpose  and  emotion  and  friends  vainly  try 
to  hold  the  struggling  patient,  are  always  hysterical. 
Retraction  of  the  head  and  arching  of  the  body  in  a  con- 
vulsion whose  nature  is  doubtful,  make  hysteria  probable, 
but  meningitis,  tetanus,  strychnia  poisoning  and  hydro- 
phobia must  be  excluded.  The  occurrence  of  a  paroxysm 
whenever  a  certain  definite  area  (hysterogenic  zone)  is  ir- 


8o  NERVOUS    AND    MENTAL    DISEASES. 

ritated,  is  evidence  of  hysteria,  even  when  the  paroxysm 
in  itself  is  of  doubtful  character.  States  of  trance,  cata- 
lepsy and  hypnotism  are  forms  of  hysteria.  Alternating 
states  of  consciousness  (double  consciousness)  are  gen- 
erally hysterical,  sometimes  epileptic.  Spasm  causing 
slow,  rhythmical  oscillation  of  any  part  of  the  body  is 
hysterical,  providing  that  organic  disease  has  been  ex- 
cluded. 

The  state  of  the  reflexes  is  of  minor  importance.  The 
knee-jerk  and  heel-jerk  are  generally  considerably  exag- 
gerated in  hysteria  while  the  plantar  reflex  is  often  dimin- 
ished or  lost.  As  this  contrast  is  very  rare  in  other  condi- 
tions it  affords  probable  evidence  of  hysteria.  A  nervous 
start  when  the  knee-jerk  is  tested,  especially  if  accom- 
panied by  a  complaint  of  peculiar  sensations,  is  also 
significant. 

The  hysterical  character  of  a  paralysis  is  recognized  by 
the  absence  of  organic  disease  and  the  presence  of  other 
symptoms  of  hysteria,  rather  than  by  anything  peculiar  in 
the  motor  loss  itself.  With  but  rare  exceptions  (chorea, 
migraine,  occupation  neurosis  and  toxic  conditions)  any 
paralysis  that  is  not  organic  must  be  regarded  as  hysterical 
and  symptoms  characteristic  of  hysteria  will  generally  be 
present.  Nevertheless,  there  are  certain  forms  of  par- 
alysis which  are  in  themselves  peculiar  to  h3rsteria. 

In  a  case  of  partial  hemiplegia,  if  the  paralyzed  leg  is 
dragged  after  the  sound  one,  instead  of  being  swung  past 
it,  and  the  foot  is  held  stiffly  at  right  angles  to  the  leg,  in- 
stead of  showing  a  tendency  to  drop  of  its  own  weight, 
the  paralysis  is  hysterical.  Inability  to  flex  or  extend  a 
joint  on  request,  although  the  same  thing  can  be  done 
automatically  when  attention  is  distracted,  is  proof  of 
hysteria.  Restraint,  by  contraction  of  the  opponents,  of 
a  movement  which  the  patient  has  been  urged  to  make 


THE    SIGNS    OF    HYSTERIA.  8t 

and  has  actually  begun  is  also  hysterical.  Paralysis  of 
the  adductors  of  the  vocal  cords,  as  indicated  by  aphonia, 
is  always  hj^sterical  when  coughing  and  sneezing  are 
normal. 

Among  the  most  characteristic  stigmata  of  hysteria  are 
the  sensory  disturbances.  All  of  these,  whether  sensory 
loss,  paresthesia,  hyperesthesia  or  pain,  are  alike  in  that 
their  location  never  corresponds  definitely  to  the  areas  of 
nerves  or  spinal  segments,  but  is  in  areas  of  a  quite  dif- 
ferent shape  or  in  isolated  spots.  Sensory  loss  is  the 
most  important,  although  it  is  probably  not  so  frequent  in 
other  countries  as  in  France.  It  occurs  in  one  of  the  fol- 
lowing forms  : 

1.  Hemianesthesia,  or  loss  of  sensibility,  generally  in- 
cluding all  kinds,  in  one  lateral  half  of  the  entire  body.  It  is 
often  accompanied  by  impairment  of  the  special  senses  on 
the  same  side,  the  impairment  of  sight  not  being  hemi- 
anopia  but  amblyopia  with  contraction  of  the  visual  field 
of  the  affected  eye  and  perhaps  a  reversal  of  the  relative 
size  of  the  color  fields.  The  left  side  is  affected  about 
three  times  as  often  as  the  right. 

2.  Anesthesia  in  so-called  geometric  areas,  as  in  the 
form  of  a  glove,  stocking  or  sleeve,  or  in  a  circle,  ellipse 
or  triangle.  Such  a  loss  usually  includes  all  kinds  of 
sensibility  and  is  especially  apt  to  be  found  over  a  par- 
alyzed or  contractured  part. 

3.  In  scattered  islets  of  variable  shape. 

Any  of  these  forms,  if  the  loss  is  great  and  well  defined, 
may  be  confidently  regarded  as  hysterical,  even  without 
the  variability  under  suggestion  or  emotional  change  which 
may  usually  be  observed.  It  is  true  that  on  theoretical 
grounds  we  might  expect  organic  disease  of  the  cortex  to 
cause  sensory  loss  in  similar  areas,  for  the  hysterical 
anesthesia   is  probably    caused   by  the  inhibition  of  cor- 


82  NERVOUS    AND    MENTAL    DISEASES. 

responding  cortical  centers,  but,  as  a  matter  of  fact,  the 
sensory  loss  of  cortical  organic  disease  is  slight  and  ill 
defined  compared  with  that  of  hysteria.  Hemianesthesia 
may  also  be  caused  by  organic  disease  of  the  internal 
capsule,  but  in  that  case  the  visual  defect,  if  any  be 
present,  is  hemianopia  and  other  signs  of  organic  change 
are  generally  unmistakable. 

Hyperesthesia  or  tenderness  in  any  of  the  geometric 
areas  just  mentioned  is  almost  as  significant  of  hysteria  as 
sensory  loss. 

The  pain  known  as  clavus,  which  is  sharply  localized  in 
a  small  area  near  the  vertex,  is  almost  invariably  hys- 
terical, but  as  a  general  rule  hysterical  pains  are  not  to  be 
distinguished  by  their  character  or  location.  It  is  rather 
the  circumstances  under  which  they  appear  and  disappear, 
the  absence  of  certain  conditions  which  accompany  ordi- 
nary pains  and  the  presence  of  other  signs  of  hysteria  that 
are  significant. 

If  a  patient  complains  of  severe  and  long-continued 
pain,  especially  if  it  is  said  to  prevent  sleep,  and  yet  there 
is  no  loss  of  weight  or  disturbance  of  pulse  and  the  facial 
expression  is  not  indicative  of  suffering,  the  pain  is  prob- 
ably hysterical. 

When  a  patient  complains  of  intense  pain  awakened  by 
the  lightest  touch  or  slightest  change  of  posture  and  yet 
makes  no  complaint  when  considerable  pressure  is  indi- 
rectly applied  to  the  same  part,  the  hysterical  character  of 
the  pain  is  certain.  For  example,  in  the  hysterical  imita- 
tion of  hip  disease  the  slightest  visible  disturbance  of  the 
joint  may  appear  to  cause  great  agony,  but  the  foot  maybe 
pushed  upward  so  as  to  press  the  head  of  the  femur  firmly 
into  the  cotyloid  cavity  without  causing  any  sign  of  pain ; 
and  in  the  hysterical  imitation  of  Pott's  disease  there  is  the 
same  superficial  tenderness  yet  the  patient  may  experience 


THE    SIGNS    OF    HYSTERIA.  83 

a  sudden  jar  of  the  spine  or  a  downward  pull  on  the 
shoulders  without  wincing.  In  many  cases  of  this  kind 
simply  calming  the  fears  and  diverting  the  attention  of  the 
patient  to  other  things  will  cause  all  signs  of  pain  to  dis- 
appear. 

A  visual  defect  may  sometimes  be  the  first  convincing 
sign  of  hysteria.  Dimness  of  vision  which  may  be  cor- 
rected by  appropriate  suggestion  accompanying  the  use  of 
a  plain  glass,  or  two  glasses  which  neutralize  each  other, 
must  of  course  be  hysterical.  Many  of  the  cases  in 
which  eye-strain  and  various  nervous  disturbances  appear 
to  be  relieved  by  very  weak  glasses  or  by  a  slight  change 
in  the  balance  of  the  ocular  muscles  are  of  the  same 
nature.  Concentric  contraction  of  the  visual  field  of  one 
eye  with  reversed  relation  of  the  color  fields  (red  field 
greater  than  blue,  or  green  greater  than  red)  is  generally 
regarded  as  proof  of  hysteria,  but  unless  there  are  other 
signs  of  hysteria  its  significance  is  doubtful.  Monocular 
diplopia  or  polyopia,  in  the  absence  of  a  gross  error  of 
refraction,  is  almost  certainly  hysterical.  Intense  photo- 
phobia in  the  absence  of  any  inflammatory  condition  that 
could  cause  it  is  proof  of  hysteria. 


84  NERVOUS    AND    MENTAL    DISEASES. 


THE  DIAGNOSIS  OF  NEURASTHENIA. 

Neurasthenia  is  a  state  of  functional  weakness  of  the 
nervous  system  generally,  especially  of  the  higher  centers. 
An  uncomplicated  case  is  recognized : 

1.  By  the  absence  of  symptoms  characteristic  of  organic 
disease  of  the  nervous  system,  heart,  lungs  or  other 
organs,  and  of  those  characteristic  of  hysteria  or  any  of  the 
psychoses  such  as  mania,  melancholia  or  paranoia. 

2.  By  a  history  of  some  of  the  causes  of  nervous  ex- 
haustion, particularly  a  neurotic  inheritance,  exhausting 
diseases,  injuries,  emotional  strain,  overwork,  sexual  ex- 
cesses, toxic  conditions  and  insufficient  food. 

3.  By  signs  of  irritable  weakness  of  the  higher  cortical 
centers.  Among  the  most  important  of  these  are  («)  lack 
of  zest  for  work,  feeling  of  inability  to  concentrate 
thoughts  or  arrive  at  a  decision,  complaint  of  failing 
memory  but  with  a  good  recollection  of  events,  early 
onset  of  mental  fatigue ;  [b)  morbid  sensations  in  the 
head,  not  amounting  to  actual  pain  but  consisting  of  rather 
vague  feelings  of  soreness,  dizziness,  weight,  constriction, 
increased  volume,  vacancy,  confusion,  etc.  ;  (c)  feelings 
of  soreness  or  distress  in  the  spine,  heart,  stomach  and 
other  organs  ;  {d)  excessive  sensitiveness  to  trifling  annoy- 
ances ;  {e)  irrational  fears,  consisting  of  a  vague  sense  of 
impending  evil  or  dread  of  bodily  or  mental  disease  or 
occurring  in  paroxysms  analogous  to  the  stage  fright  of 
normal  individuals ;  these  may  be  excited  in  a  great 
variety  of  ways,  e.  g.,  being  in  the  presence  of  a  crowd, 
being  alone,  in  a  closed  room,  in  an  open  space,  near  a 


THE    DIAGNOSIS    OF    NEURASTHENIA.  85 

building,  in  the  dark,  crossing  a  bridge,  etc.  ;  (_/")  in- 
ability to  divert  the  mind  from  a  certain  thought  or  phrase, 
usually  of  an  indifferent  or  unpleasant  character,  which 
keeps  recurring  like  a  too-familiar  tune  and  may  impel  to 
fatiguing  and  perhaps  dangerous  actions,  such  as  count- 
ing, touching  the  posts  that  may  be  passed,  reading  all 
the  signs  on  the  street,  following  an  absurd  train  of  reason- 
ing, etc.  ;  if  the  impulse  is  resisted  a  feeling  of  distress 
occurs  and  often  compels  the  patient  to  resume  the  tire- 
some performance  ;  these  morbid  thoughts  and  impulses 
are  not  so  common  as  the  other  symptoms  of  neurasthenia, 
are  more  difficult  to  cure  and  in  rare  cases  pass  into 
actual  insanity ;  (g-)  impaired  vasomotor  control,  cardiac 
palpitation,  nervous  indigestion,  sexual  debility,  increased 
tendon  and  muscle  reflexes  and  tremor. 


86  NERVOUS    AND    MENTAL    DISEASES. 


MIXED  FORMS  OF  DISEASE. 

In  studying  a  disease  we  necessarily  learn  it  first  in  its 
uncomplicated  form,  but  in  practice  we  often  find  a  patient 
to  besuffering  from  two  or  more  diseases  at  the  same  time. 
Thus  organic  disease  of  the  brain  is  often  complicated  b}^ 
epilepsy  or  hysteria ;  hysteria  and  neurasthenia  are  often 
mingled,  and  either  may  be  added  to  epilepsy  or  migraine  ; 
myelitis  may  complicate  a  cerebral  disease,  and  so  on 
almost  indefinitely.  Such  complications  are  very  likely 
to  lead  to  an  incomplete  diagnosis,  for  it  is  natural  to  feel 
that  the  diagnosis  is  made  as  soon  as  one  disease  is  recog- 
nized, and  the  mind  has  a  strong  tendency  to  ignore 
symptoms  which  do  not  harmonize  with  an  opinion  already 
formed. 

The  only  way  to  avoid  being  misled  by  such  cases  is 
not  only  to  know  the  symptoms,  course  and  possible  compli- 
cations of  each  disease,  but  also  to  form  the  habit  of 
investigating  anomalous  symptoms  with  especial  care. 


RECOGNITION    OF    SPFX'IAL    DISEASES.  87 


THE    RECOGNITION    OF    SPECIAL 
DISEASES. 

EXPLANATION    OF    TABLES. 

The  use  of  the  following  diagnostic  tables  is  so  simple 
that  any  explanation  may  seem  superfluous.  After  a 
thorough  examination  of  the  patient  a  prominent  symptom 
is  selected,  an  objective  one  like  paralysis,  spasm  or  optic 
neuritis,  if  it  be  present,  and  the  corresponding  table  is 
found.  Then  the  general  descriptions  marked  by  Roman 
numerals  are  compared  in  regular  order  with  the  symptoms 
of  the  case,  stopping  at  the  one  which  agrees  with  them. 
Under  this  division  will  be  found  a  number  of  coordinate  sub- 
divisions, each  marked  by  a  capital  letter.  These  are  to 
be  compared  with  the  case  in  regular  order  until  the  right 
one  is  found,  and  so  on  through  the  various  subdivisions 
until  the  individual  disease  is  reached.  Whenever  the 
general  description  does  not  harmonize  with  the  symptoms 
of  the  case  it  is,  of  course,  necessary  to  pass  over  all  that 
may  be  included  under  it  and  go  on  to  the  next  coordinate 
division,  which  is  always  marked  by  the  next  character  of 
the  same  kind.  It  will  sometimes  occur  that  divisions  in 
the  table  are  made  according  to  the  presence  or  absence  of 
symptoms  which  have  been  entirely  overlooked  in  the  ex- 
amination ;  in  such  a  case  the  only  remedy  is  to  complete 
the  examination  at  the  next  opportunity. 

The  most  critical  point  in  the  diagnosis  will  generally 
be  the  decision  as  to  whether  or  not  there  is  organic 
disease.     Of  the  symptoms  mentioned  in  the  tables  as  indi- 


b»  NERVOUS    AND    MENTAL    DISEASES. 

eating  it,  some  are  absolutely  conclusive,  but  others,  taken 
singly,  denote  only  a  strong  probability  of  its  existence. 
The  weight  to  be  given  to  these  symptoms  has  already 
been  considered.  It  must,  of  course,  happen  in  some 
cases  that  the  existence  or  absence  of  organic  disease 
cannot  be  determined  with  certainty.  In  such  a  case  the 
ph3^sician  may  assume  each  possibility  in  turn  and  by 
comparing  the  resulting  diagnoses  come  to  a  probable 
conclusion,  or  he  may  have  to  wait  for  further  symptoms 
to  develop. 

Whenever  feasible  both  the  pathological  and  the  locali- 
zation diagnosis  are  given  together,  but  where  necessary 
a  supplementary  table  on  localization  has  been  added. 


HEMIPLEGIA.  89 


HEMIPLEGIA. 

Paralysis  of  the  leg,  arm  and  tongue  on  one  side  and  of 
the  lower  part  of  the  face  on  the  same  side  or,  very  rarely, 
on  the  opposite  side. 

I.   Occurs    at    birth.       Onset    often    marked    by    convulsions. 
Epilepsy  and  mental  defect  common  in  survivors. 

Cerebral  Birth  Palsy^  usually  due  to  meningeal 
hemorrhage. 
II.  Occurs  in  infancy,  usually  in  the  course  of  an  infectious  dis- 
ease. Onset  sudden  or  very  rapid,  in  most  cases  marked 
by  convulsions.  Aphasia  accompanies  right  hemiplegia  if 
the  child  has  learned  to  talk.  Epilepsy  and  mental  defect 
common  in  survivors. 

Infantile  Cerebral  Palsy.,  uszially  due  to  thrombosis  in 
cortical  veins. 
III.   Occurs  after  infancy. 

A.  Onset  sudden  or  very  rapid  (in  a  few  seconds  to  a  few 
hours) ,  generally  marked  bv  loss  or  disturbance  of  con- 
sciousness, v^dth  or  without  convulsions.  Aphasia  ac- 
companies right  hemiplegia  but  is  often  transitory. 

1.  The  attack  is  preceded  by  evidences  of  uremia,  par- 
ticularly a  great  diminution  in  the  amount  of  the  total 
urinary  solids,  albuminuria  and  casts  and  a  character- 
istic pallor,  edema  or  retinitis.  The  paralysis  quickly 
disappears  if  free  secretion  of  urine  can  be  secured. 
Rare.  Uremic  Paralysis. 

2.  The  attack  is  preceded  by  symptoms  of  chronic,  or- 
ganic, inental  or  nervous  disease.  Onset  often  marked 
by  convulsions.  Temperature  rises  rapidly  to  101° 
or  more.  Paralysis  generally  passes  aw^ay  in  a  few 
days  if  the  patient  survives. 


90  NERVOUS    AND    MENTAL    DISEASES. 

a.  History  of  gradually  increasing  dementia  and  often 
of  delusions  of  grandeur,  indistinctness  of  speech, 
incoordination  or  weakness  of  limbs,  etc. 

Apoplectiform  Attack  ht  Paretic  De77ientia. 

b.  History  of  intention  tremor,  transient  paralysis  or 
amblyopia,  nystagmus,  scanning  speech  or  other 
symptoms  of  disseminated  sclerosis. 

Apoplectiform  Attack  in  Disseminated  Scle- 
rosis. 
3.  The  attack  is  not  preceded  by  symptoms  of  chronic, 
organic,  mental  or  nervous  disease.  The  paralysfs  is 
permanent  or  disappears  slowly.  Within  a  few 
days  of  the  attack  the  tone  of  the  affected  muscles  and 
their  tendon  reflexes  are  increased. 

a.  No  prodromata.  Endocarditis  or  pulmonary  ab- 
scess present  at  time  of  onset.  No  marked  initial 
fall  of  temperature.     Age  usually  less  than  40. 

Cerebral  Embolism. 

b.  Prodromata  (nocturnal  headache,  transient  weak- 
ness, tingling,  mental  dullness,  etc.)  common. 
Syphilis  present  or  at  least  not  exclvided.  No 
other  cause  of  arterial  degeneration.  No  cause  of 
embolism.  No  evidence  of  increased  blood  pres- 
sure at  time  of  onset  nor  marked  initial  fall  of 
temperature.     Age  usually  less  than  40. 

Syphilitic  Thro7nbosis. 

c.  The  onset  follows  an  injury  to  the  head,  either 
immediately  or  after  a  short  interval,  and  is  very 
rapid  rather  than  sudden.  The  paralysis  is  often 
preceded  by  convulsions  on  the  same  side  and  by 
severe  headache  on  the  opposite  side,  followed  by 
sopor,  coma  and  slowness  of  pulse. 

Mening^eal  Hemorrhage. 

d.  Arteries  weakened  by  atheroma  or  infectious  dis- 
ease. Evidence  of  increased  blood  pressure  at 
time  of  onset,  such  as  a  tense  pulse,  cardiac  hyper- 
trophy, muscular  exertion,  excitement,  etc.     Tem- 


HEMIPLEGIA.  9I 

peraturc  usually  falls  one  degree  or  more  within  a 
few  hours.      Age  usually  more  than  40. 

Cerebral  Hemorrhage. 
e.  Evidence  of  lowered  blood  pressure  at  the  time  of 
onset  together  with  arterial  disease  (especially  the 
atheroma  of  advanced  age) ,  or  with  increased 
coagulabilit}^  of  the  blood,  as  in  the  puerperium, 
phthisis,  gout,  cancer,  etc.  Fall  of  temperature 
slight  if  any.  Coma  generally  not  profound. 
Prodromata  common ;  onset  often  rapid  rather 
than  sudden.  Cerebral  Thrombosis. 

B.   Onset  gradual   in  a  few  hours   or   longer.     Headache, 

often  accompanied  by  vomiting,   usually  precedes    any 

disturbance  of  consciousness. 

I.   Onset  rapid  in  a  few  hours  to  a  few  days. 

a.  Attack  follows  an  injury  to  the  head  without  intra- 
cranial infection,  or  occurs  in  a  patient  who  is  al- 
coholic or  chronically  insane.  The  paralysis  is 
often  preceded  by  convulsions  on  the  same  side 
and  by  severe  headache  on  the  opposite  side,  fol- 
lowed by  sopor,  coma  and  slowness  of  pulse. 

Aleningeal  Hemorrhage. 

b.  There  is  an  infected  wound  of  the  head  or  caries 
of  the  skull,  ^vith  correspondingly  localized  head- 
ache, on  the  side  opposite  the  paralysis.  Fever 
with  gradual  development  of  delirium,  sopor 
and  coma.  External  Pachymejiingitis. 

c.  A  source  of  intracranial  infection  or  irritation  is 
present,  c.  g..,  purulent  otitis  media,  tuberculosis, 
pneumonia,  epidemic  influence  or  sunstroke.  On- 
set marked  by  headache  and  fever,  often  accom- 
panied by  vomiting.  General  hyperesthesia  ex- 
ists at  first,  but  is  soon  followed  by  delirium 
which,  in  severe  cases,  merges  into  stupor  and 
coma,  headache  persisting  as  long  as  the  patient 
can  answer  questions.  Retraction  of  the  head, 
localized  twitching  and  general    convulsions    are 


NERVOUS    AND    MENTAL    DISEASES. 

common.  Other  paralyses  may  occur,  especially 
in  the  ocular  muscles.  Optic  neuritis,  rarely  in- 
tense, is  common  in  the  more  protracted  cases 
when  the  disease  is  at  the  base,  rare  when  it  is 
over  the  convexity. 

Meningitis^  possibly  Cerebritis  or  Abscess. 
Onset  acute  or  chronic,  in  a  few  days  to  weeks  or 
months.  A  source  of  purulent  infection  is  present, 
e.  ^.,  otitis  inedia,  empyema,  abscess  in  any  part  of  the 
body,  infected  wound  of  the  head,  etc.  Temperature 
irregular,  generally  elevated,  but  sometimes  depressed. 
Rigors  followed  by  fever  and  sweating  common. 
Optic  neuritis  freqvient,  but  rarely  intense.  Focal 
cerebral  syinptoms  (Fig.  14)  common  and  cranial 
nerve  symptoms  uncommon  in  comparison  with  men- 
ingitis. Dvn-ation  may  be  short  or  it  may  be  very  long 
with  a  period  of  latency.  Intracranial  Abscess. 

Onset  gradual  and  slow,  in  six  weeks  to  six  months 
or  longer.  No  evidence  of  suppuration.  Tempera- 
ture mostly  normal. 

a.  Headache  usually  intense,  often  accompanied  by 
vertigo  and  vomiting.  Optic  neuritis  in  four- 
fifths  of  all  cases,  often  intense.  Pulse  often 
slow.  Convulsions  or  any  form  of  focal  (Fig.  14) 
or  cranial  nerve  symptom  may  occur.  Course 
usually  long  and  for  the  most  part  steadily  pro- 
gressive, with  mental  failure  toward  the  end.  In- 
herited or  acquired  predisposition  to  new  growths 
sometimes  apparent. 

Intracranial  Tumor.,  Aneurism  or  Cyst. 

b.  Headache  chiefly  nocturnal.  Optic  neuritis  absent 
or  slight.  Syphilis  present  or  at  least  not  ex- 
cluded. Focal  or  cranial  nerve  symptoms  may 
occur  as  in  tumor.  Syphilitic  Meningitis. 

c.  Age  usually  more  than  60.  Headache  often  ab- 
sent, rarely  intense.  No  optic  neuritis  nor  other 
cranial  nerve  symptom.      Convulsions  very  rare. 


HEMIPLEGIA. 


93 


Aphasia  and  dementia  may  gradually  occur. 
Course  slowly  progressive  up  to  a  certain  point, 
but  then  may  be  arrested  for  a  time.  Duration 
from  onset  to  fatal  ending  varies  from  a  few 
months  to  two  years.      Rare. 

Chronic  Progressive  Cerebral  Softening. 


Fig.  15. 


Lesion    of    cerebral 
monoplegia  (brachial) 


Lesion    of   ordinary 
hemiplegia. 


Lesion  of  cross  paralysis 
(face  of  same  side  with 
limbs  of  other  side). 


Cortical  center  for  op- 
posite leg. 


Cortical  center  for  op- 
posite arm. 


Cortical  center  for  op- 
posite side  of  face. 

Internal    capsule   (pos- 
terior limb). 


—  Motor  nerve  to  face. 

Decussation    of  pyra- 
mids. 

Crossed    pyramidal 
tract. 


Motor  nerves  to  upper 
limb. 


Crossed  pyram^idal  tract. 


Sensory  nerves  entering 
cord,  and  decussating 
soon  after  entry. 


Motor  nerves  to  lower 
limb. 


Diagram  to  show  the  General  Arrangement  of  the  Motor  Tract,  and  the 
Effect  of  Lesions  at  Various  Points.    {From  Omierod.) 


A  lesion  causing  para- 
plegia. 

A  lesion  causing  hemi- 
paraplegia. 


94  NERVOUS    AND    MENTAL    DISEASES. 


LOCALIZATION    DIAGNOSIS    IN    HEMIPLEGIA. 

I.   The  hemiplegia  is  preceded  or  accompanied  by  a  symptom 
characteristic    of    involvement   of    the   cortex,   particularly 
Jacksonian  epilepsy,  epileptic  attacks  having  a  definitely 
localized  sensory  aura,  a  definite  form  of  aphasia  or  an  in- 
tellectual defect  which  cannot  be  regarded  as  a  temporary 
or    indirect    result    of    the    lesion.     If    the    symptoms    are 
gradually  developed  the  paralysis  begins  in  a  single  limb  or 
one   side   of  the  face  (monoplegia)  and  becomes  a  hemi- 
plegia by  extension  to  the  adjacent  parts.    (Figs.  14  and  15.) 
Lesion  in  or  immediately  beneath  the    Cortex^  begin- 
jzing-  in  the  pai-t  corresponding  to  the  earliest  dis- 
turbance of  motioft^  sejtsation  or  speech. 
II.   The  paralysis  begins  as  a  monoplegia  and  gradually  extends 
to  hemiplegia.      There  are  no  Jacksonian  attacks  or  local- 
ized sensory  auree  and  no  aphasia  or  intellectual  loss  except 
such  general  defect  as  may  result  from  the  pressure  or  irri- 
tation of  a  rapidly  growing  tumor  or  abscess.      There  may 
be  slight  sensory  loss  in  the  jDaralyzed  limbs,  but  there  is  no 
definite  hemianesthesia.       Lesion  of  the   Cejitriun   Ovale. 

III.  Hemianesthesia,  with  or  without  hemianopia,  accompanies 
the  hemiplegia.  There  may  be  pains  in  the  paralyzed 
limbs.  Lesion  in  or  near  the  Internal  Capsule. 

IV.  There  is  mobile  spasm  (athetosis)  or  incoordination  (post- 
hemiplegic chorea)  of  the  paralyzed  hand.  Pains  in  the 
paralyzed  limbs  common.  Lesion  of  the  Thalamus. 

V.   Paralysis  of   all  or  a  part  of   the  muscles  supplied  by  the 

third  nerve  or  of  the  superior  oblique  occurs  at  the  same 

time  as  the  hemiplegia,  but  on  the  opposite  side.     May  be 

accompanied  by  hemianopia,  especially  in  cases  of  tumor. 

Lesion  of  the  Crus  or  uppertnost  part  of  the  Pons. 


LOCALIZATION    DIAGNOSIS    IN    HEMIPLEGIA.  95 

VI.  The  paralysis  of  the  limbs  is  accompanied  by  paralysis  of 
the  face,  external  rectus  or  muscles  of  mastication,  or  by 
anesthesia  of  the  face,  on  the  opposite  side.  Swallowing 
and  articulation  likely  to  be  impaired.  Trismus  and  gen- 
eral rigidity  may  occur.  In  acute  lesions  hyperpyrexia  is 
common  and  death  generally  occurs  in  a  very  short  time. 

Lesion  of  the  Pons. 
VII.   The  symptoms  are  not  characteristic  of  any  definite  location. 
Lesion  of  the  Internal  Capsule  to  be  assumed  as  the 
most  probable. 


96  NERVOUS    AND    MENTAL    DISEASES. 


PARTIAL   HEMIPLEGIA— MONOPLEGIA. 

Paralysis  of  arm  and  leg  or  of  arm  and  lower  part  of 
face  on  one  side,  or  paralysis  of  one  limb  or  of  lower  part 
of  one  side  of  the  face. 

I.   There  is  organic  disease  of  the  nervous  system,  shown  by 
such  signs  as  paralysis  of  ocular  muscles,  face,  tongue  or  one 
side  of  larynx  ;   paralysis  and  sensory  loss  both  correspond- 
ing to  the  function  of  definite  nerve  trunks  or  spinal  seg- 
ments ;   loss  of  faradic  irritability;   absence  of  knee-jerk; 
typical  ankle  clonus  ;  optic  neuritis  or  optic  atrophy ;  fail- 
ure of  light  reaction ;   Jacksonian  epilepsy,  etc. 
A.   The  paralyzed  muscles  are  flabby  and  soon  waste,  their 
tendon   reflexes  being   lost  and  faradic  irritability  lost 
or  impaired.      Control  of  bladder  and  rectum  retained. 
I.   Onset  acute,  in  a  few  hours  to  a  few  days,  and  re- 
sembles that  of  an  eruptive  fever,  possibly  marked 
by  convulsions,  often  attended  by  rheumatoid  pains. 
No  sensory  loss.      Six-sevenths  of  all  cases  in  chil- 
dren under  ten  years  of  age.  Poliomyelitis. 
3.   Onset  acute,  subacute  or,  rarely,  chronic,  in  one  to 
six  weeks  or  longer.      Paralysis,  together  with  numb- 
ness, tingling  pain  and  more  or  less  sensory  loss,  is 
in  the  distribution  of  certain  nerves.     Muscles  and 
nerve  trunks  generally  tender. 

a.   An  arm  affected.      The  apparent  cause  is  gout, 
rheumatism,  exposure,  fracture  of  humerus,  pres- 
sure of  new  grovk'ths  or  wounds  of  the  arm  or 
shoulder. 
Neuritis  involving   brachial    plexus,   nerves 
or  nerve  roots. 


PARTIAL    HEMIPLEGIA MONOPLEGIA.  97 

b.  A  leg  affected.  The  apparent  cause  is  vertebral 
caries,  pelvic  inflammation,  pressure  of  new 
grow^ths,  an  infected  wound  of  a  nerve  or  an 
injury  about  the  hip. 

Neuritis   involving  lumbar  and  sacral  flex- 
uses. 
B.  No  wasting   nor   loss  of   fai'adic  irritability.     Paralysis 
spastic  ;  tendon  reflexes  exaggerated. 

1.  No  cerebral  or  cranial  nerve  symptoms.  Leg  or  leg 
and  arm  paralyzed.  Loss  or  diminution  of  sensibility 
to  pain,  temperature  and  touch  in  an  area  correspond- 
ing to  that  of  the  paralysis  but  on  the  opposite  side. 

Unilateral  Lesion  of  Spinal  Cord. 

2.  Cerebral  and  cranial  nerve  symptoms  common.  Sen- 
sory loss,  if  any,  is  on  the  same  side  as  the  paralysis 
but  is  visually  slight  in  comparison  with  it  and  does 
not  correspond  to  the  distribution  of  nerve  trunks  or 
spinal  segments. 

Diagnosis  same  as  in  Hemiplegia. 
IL   All  positive  signs  of  organic  disease  absent. 

A.  The  paralysis  occurs  as  a  complication  of  chorea  and  is 
generally  a  monoplegia,  sometimes  a  partial  hemiplegia. 
No  reaction  of  degeneration.  There  may  be  some  sen- 
sory loss.  Always  passes  away  in  the  course  of  a  few 
weeks.  Choreic  Paralysis. 

B.  Onset  variable;  if  sudden  it  may  suggest  apoplexy, 
especially  when  it  occurs  in  an  hysterical  fit ;  if  gradual 
the  paralysis  may  advance  in  steps  from  one  joint  to  the 
next. 

An  emotional  cause  is  often  distinctly  apparent.  Sus- 
ceptibility to  suggestion  is  apparent  in  the  history  or  at 
the  examination.  History  of  hysterical  attacks  common. 
Hysterogenic  zones  may  perhaps  be  found.  Symptoms 
often  vary  greatly  with  emotional  changes. 

When  the  patient  is  urged  to  attempt  a  movement  the 
opposing  muscles  may  often  be  seen  to  resist  it.  If  at- 
tention be  diverted  acts  requiring  the  use  of  the  paralyzed 


98  NERVOUS    AND    MENTAL    DISEASES. 

muscles  may  perhaps  be  performed  automatically. 
Under  encouragement,  especially  if  electricity  or  other 
local  treatment  has  been  used,  a  far  greater  movement 
may  be  made  than  at  first  seemed  possible.  When  the 
leg  is  involved  and  the  patient  walks,  the  toes  do  not, 
as  in  organic  paralysis,  keep  to  the  ground  from  the 
mere  w^eight  of  the  foot,  necessitating  an  exaggerated 
motion  of  the  hip  by  which  the  lame  foot  is  swung  in 
advance  of  the  sound  one ;  on  the  contrary,  the  foot  is 
often  held  in  a  fixed  position  and  is  usually  dragged  after 
the  sound  one  instead  of  advancing  before  it. 

Sensory  loss  is  often  more  extensive  and  profound 
than  the  paralysis  and  its  distribution  is  characteristic 
of  hysteria,  being  most  commonly  in  the  form  of  hemi- 
anesthesia with  corresponding  impairment  of  the  special 
senses,  or  in  areas  bounded  by  the  external  lines  of  the 
body  or  by  circular  lines  around  a  limb,  or  in  geometric 
areas,  but  never  corresponding  exactly  to  the  distribu- 
tion of  particular  nerves  or  spinal  segments. 

Hysterical  Paralysis. 


LOCALIZATION    DIAGNOSIS. 


99 


LOCALIZATION    DIAGNOSIS   IN   PARTIAL 
HEMIPLEGIA   AND    MONOPLEGIA. 

For  most  cases  the  seat  of  the  lesion  has  already  been 
sufficiently  indicated.  In  cases  of  spastic  partial  hemi- 
plegia or  monoplegia  of  intracranial  origin,  localization 
depends  on  the  same  principles  as  in  hemiplegia  (which 
see),  but  the  lesion  is  almost  always  in  the  cortex  or  cen- 
trum ovale,  because  there  the  motor  tract  is  so  spread  out 
as  to  admit  of  the  fibers  for  the  face,  arm  or  leg,  being 
damaged  separately  ;  in  the  internal  capsule,  crus  or  pons, 
these  fibers  are  so  close  together  that  a  lesion  of  any  con- 
siderable size  must  affect  all  of  them  and  so  cause  a  com- 
plete hemiplegia. 


lOO  NERVOUS    AND    MENTAL    DISEASES. 


PARAPLEGIA— DOUBLE   HEMIPLEGIA. 

Both  legs  are  paralyzed,  with  or  without  paralysis  of  the 
arms  and  face. 

I.  Organic  disease  of  the  nervous  system  is  shown  to  be  pres- 
ent by  some  positive  sign,  e.  g.^  paralysis  and  sensory  loss 
corresponding  definitely  to  the  distribution  of  nerves  or  the 
function  of  spinal  segments,  angular  deformity  of  spine, 
girdle  sensation  or  other  root  symptoins,  degenerative 
atrophy  of  muscles,  loss  of  faradic  irritability,  absence  of 
knee-jerk,  typical  ankle  clonus,  paralysis  of  face,  tongue, 
ocular  inuscles  or  one  side  of  larynx,  optic  neuritis  or 
atrophy,  absence  of  light  reaction,  etc. 

A.  There  is  no  paralysis,  spasin  or  sensory  loss,  except  in 

parts  innervated  by  the  spinal  cord  and  in  such  form  as 

to  be  accounted  for  by  disease  of  the  cord  itself. 

I .   There  is  inore  or  less  sensory  loss  in  addition  to  the 

paralysis,  the  upper  limit  of  both  corresponding  to  a 

segment  of  the  spinal  cord,  generally  combined  with 

disturbed   action  of    the  bladder   and   rectum.      Not 

preceded  by  localized  spinal  pain  and  rigidity. 

a.  Onset  sudden  in  a  few  moments. 

i.   Simultaneous    with     severe     injury    to     spinal 
column. 

Fracture  or  Dislocation  of  Vertebrce^  Wound 
of  or  Hemorrhage  into  Cord. 
ii.   Withovit  external  violence. 

Heffiorrhage  into  Cord. 

b.  Onset  gradual,  acute  or  chronic.  VertebrEe  not 
diseased.  Pain  rarely  a  proininent  symptom,  al- 
though some  dull  pain  is  usually  present. 

Myelitis. 


PARAPLEGIA DOUBLE    HEMIPLEGIA.  lOI 

Paralysis  preceded  by  localized  spinal  pain  and  rigid- 
ity;    corresponding  radiating  pains  common.     Paral- 
ysis of   legs  spastic  with  exaggeration  of   knee-  and 
Achilles-jerks,  unless  the  disease  be  low  enough  to 
involve  the  lumbar  enlargement,  in  which  case  wast- 
ing and  loss  of  tendon  reflexes  will  be  found.      Sen- 
sory loss  and  disturbance  of  bladder  and  rectum  may 
or  may  not  be  added  to  th'i  other  symptoms. 
a.   Deformitv    or    swelling,    often    with   deep-seated 
tenderness,  indicates  disease  of  the  vertebrae, 
i.   Patient  most    commonly   a   child,    sometimes 
an    adult,    rarely    an     elderly     person.      The 
tubercular   diathesis   is  almost  always    mani- 
fest,   but    very    rarely    svphilis    may    be    the 
cause.       The    pain,    generally    of     moderate 
severity,  is  increased  by  motion  or  jars   and 
diminished  by  rest  of  spine.     Prominence  or 
lateral  displacement  of   one  or  more   spinous 
pi'ocesses  the  characteristic  deformitv. 

SpiJtal  Caries. 

ii.   Patient  generally  in  second  half  of  life.    There 

may  be  a  history  of   tumor  elsewhere  or  of 

predisposition  to  new  growths  or  to  aneurism. 

Pain   very  intense  and  greatly  aggravated  by 

motion. 

§   Radiating    pain    on    left    side   of    thorax, 

mainly  in  the  areas  of  the  fifth  and  sixth 

dorsal  segments.      Thrill  and  murmur  at 

seat  of  deformity. 

Aneurism  eroding  Spine. 
§§   Pain   on   both   sides.     No   thrill  or   mur- 
mur. Ttimor  of  Spine. 
b.   Nothing  to  indicate  disease  of  vertebrae. 

i.  Onset  sudden  or  rapid  after  passing  from  an 
air  pressure  of  three  atmospheres  or  more  to 
the  ordinary  pressure.  Headache,  giddiness, 
abdominal  pains  and  vomiting  common. 

Caisson  Disease. 


I02  NERVOUS    AND    MENTAL    DISEASES. 

ii.   Onset  sudden.     No  fever  at  first. 

Spinal  Me7iingeal  Hemorrhage. 
iii.   Onset  gradual  but  rapid,  marked  by  chill  and 
fever.  Acute  Spinal  Meningitis. 

iv.  Onset  gradual  and  slov\^. 

§   History    of    alcoholism,    syphilis    or    ex- 
posure to  cold. 

Chronic  Spinal  Meningitis. 
§  §   Evidence  of  predisposition  to  nev^  grow^ths. 
No  other  cause  of  meningitis. 

Intraspinal  Tumor. 
B.  Symptoms  in  parts  innervated  by  the  spinal  cord  greatly 
predominate  over  such  cerebral  or  cranial  nerve  symp- 
toms as  may  occur  and  often  exist  alone.  No  localized 
spinal  pain,  rigidity  or  radiating  pains. 
I.  Paralysis  alw^ays  flabby  with  loss  of  tendon  reflexes. 
Onset  acute  or  subacute. 

a.  Onset  in  a  ie.w  hours  to  a  few  days  and  resembles 
that  of  an  eruptive  fever ;  often  marked  by  vomit- 
ing, sometimes  by  convulsions  ;  attended  by  rheu- 
matoid pains.  Paralysis  is  usually  unequal  on  the 
two  sides  and  is  rapidly  followed  by  wasting  and 
loss  of  faradic  irritability.  Anterior  tibial  grovip 
and  peronei  generally  most  affected.  No  disturb- 
ance of  bladder  or  rectum.  No  sensory  loss.  Six- 
sevenths  of  all  cases  occur  in  children  under  ten 
years  of  age.  Poliomyelitis. 

b.  Onset  acute.  Paralysis  begins  in  legs  and  ascends 
rapidly  through  trunk  to  arms.  No  wasting  or 
change  in  electrical  reactions.  No  severe  pain. 
There  may  be  slight  and  ill-defined  sensory  loss 
and  perhaps  disturbance  of  bladder  and  rectum. 
Fever  generally  absent.  Most  cases  occur  in 
early  adult  life  during  convalescence  from  some 
acute  infectious  disease  or  after  exposure  to  cold. 

Acute  Ascending  Paralysis. 

c.  Onset  acute  or  subacute,  in  one  to  four  weeks  or 


PARAPLEGIA DOUBLE    HEMIPLEGIA.  IO3 

more.      Paralysis,  numb,  stinging  pain  and  more 
or  less  sensory  loss  are  in  the  distribution  of  pe- 
ripheral nerve  trunks,  especially  the  external  pop- 
liteal  and    musculo-spiral.     Muscles    and    nerves 
tender.     Bladder  and  rectum  ver}^  rarely  involved. 
Usually  a  history  of  alcoholism,  metallic  poison- 
ing,  diphtheria,    septicemia,   extraordinary    exer- 
tion or  exposure  to  cold.  Multiple  Neuritis. 
3.   Paralysis    spastic   with    exaggeration   of    tendon   re- 
flexes.     Onset  of  disease  aWays  slow,   although  in 
disseminated  sclerosis  paralysis  and  other  symptoms 
may    come    on    rapidly.     Bladder    and    rectum    not 
affected  until  disease  is  far  advanced. 

a.  Paralysis  is  accompanied  by  intention  tremor, 
nystagmus,  scanning  speech  or  other  signs  of 
scattered  lesions.  Disseminated  Sclerosis. 

b.  No  evidence  of  disseminated  sclerosis.  No  sen- 
sory loss. 

i.  The  spastic  paraplegia  is  accompanied  by  de- 
generative muscular  atrophy  and  fibrillary 
twitching  in  the  upper  part  of  the  body,  gen- 
erally beginning  in  the  hand,  shoulder  or 
back.  Amyotrophic  Lateral  Sclerosis. 

ii.   Paraplegia  accompanied  by  ataxia. 

Poster o-lateral  Sclerosis. 
iii.   Paraplegia  without  muscular  atrophy  or  ataxia. 

Lateral  Sclerosis. 
C.   Cerebral  symptoms  predominate  over  any  signs  of  spinal 
disease  that  may  accompany  them. 

I .  Onset  acute,  inarked  by  intense  headache  and  fever. 
Delirium  occurs  early  and  is  often  followed  by  sopor 
and  coma.  Retraction  of  head  occurs  in  almost  all 
cases.  Spinal  rigidit}^  and  pain,  both  localized  and 
radiating,  together  with  cranial  nerve  symptoms, 
common.  An  eruption  of  herpes,  purpura,  urticaria 
or  erythema  occurs  in  most  cases.  No  apparent 
cause    except    epidemic     influence.     Whole    course 


I04  NERVOUS    AND    MENTAL    DISEASES. 

from  onset  to  fatal   ending  or  established  convales- 
cence varies  from  a  few  hovirs  to  a  few  months. 

Cerebro- spinal  Meningitis. 
3.  Onset  of  disease  chronic.  The  paraplegia  is  either 
spastic  or  ataxic  and  may  be  of  slow  or  rapid  onset. 
Progressive  mental  faihire  (often  with  delusions  of 
grandeur),  ineqviality  of  pupils,  stumbling  speech 
and  slight  facial  twitching  are  the  most  characteristic 
symptoms.  Paretic  Dementia. 

3.  Onset  usually  sudden  or  very  rapid,  occurring  in 
most  cases  at  birth  or  in  infancy,  but  it  may  be  slow 
and  occur  at  any  age.  No  conchtsive  sign  of  spinal 
disease  but  cerebral  symptoms  (disturbance  of  con- 
sciousness, mental  defect,  aphasia,  convulsions,  etc.) 
and  cranial  nerve  symptoms  are  common.  Paralysis 
spastic  with  exaggeration  of  tendon  reflexes  except 
for  a  short  time  immediately  after  a  sudden  onset. 
Control  of  bladder  and  rectum  sometimes  impaired 
and  involuntary  evacuations  may  also  occur  through 
inattention. 

Bilateral  Lesion  of  Hemispheres  or.,  possibly.,  a 
single  ojie  of  Pons.,  kind  of  lesion  determi7ted 
as  in  Hemiplegia.,  q.  v. 
II.   All   positive   signs    of  organic   disease    absent,  although   an 
atypical  ankle  clonus  may  be  found,  especially  in  cases  of 
long  standing  with  contracture  of  the  calf  muscles. 
A.   Onset  variable.     An  emotional  cause  is  often  apparent. 
Susceptibility  to  suggestion  is  generally  manifest  in  the 
history  or  at  the  examination.      History  of  hysterical  at- 
tacks   common ;     hysterogenic    zones    may    perhaps    be 
found.      Symptoms   often   vary   greatly  with    emotional 
changes.     When  the  patient  is  urged  to  attempt  a  move- 
ment the  opposing  muscles  may  often  be  seen  to  resist  it. 
If    attention   be    diverted    movements   of   the    paralyzed 
limbs  sometimes  occur  automatically  and  under  encour- 
agement, especially  if  electricity  or  other  local  treatment 
has  been  used,  a  far  greater  movement  may  be   made 


C1 


6:4 


D( 


10 


12 


L  / 


a 


u 


Diagram  from  an  Original  Investigation  by  W.  R.  Gowers,  Showincj  Rela- 
tion OF  Vertebral  Spines  to  their  Bodies  and  to  the 
Nerve  Roots.     (From   Tyson.) 
The  ends  of  the  vertebral  spines  are  opposite  the  middle  of  their  own  bodies  only  in 
the  lumbar  region.    They  correspond  to  the  lower  edge  of  their  own  bodies  in  the 
cervical  and  last  two  donsal,  and  to  the  upper  part  of  the  body  below  in  the  rest  of 
the  dorsal  region. 

9 


I06  NERVOUS    AND    MENTAL    DISEASES. 

than  at  first  seemed  possible.  Sensory  loss  is  cotnmon, 
never  corresponding  to  the  distribution  of  particular 
nerves  or  spinal  segments,  but  in  areas  bounded  by  the 
external  lines  of  the  body  or  by  circular  lines  around  a 
limb,  or  in  geometric  areas.  Hysterical  Paraplegia. 
B.  Paraplegia  does  not  appear  w^hen  the  patient  is  lying 
down  but  only  on  attempting  to  walk  or  stand  or,  rarely, 
while  sitting.  The  affection  is  usually  hysterical  but 
not  always  ceilainly  so.  Astasia  Abasia. 


LOCALIZATION    DIAGNOSIS.  IO7 


LOCALIZATION    DIAGNOSIS   IN    PARAPLEGIA 
AND    DOUBLE    HEMIPLEGIA. 

S-pinal  Localization. — The  spinal  cord  is  hypothetically 
divided  into  segments,  each  one  being  numbered  like  the 
pair  of  nerves  connected  with  it ;  thus  we  have  eight  cerv- 
ical, twelve  dorsal  (or  thoracic),  five  lumbar  and  five  sacral 
segments.  Each  of  these  segments  is  higher  than  its  cor- 
responding vertebra  ;  the  relation  of  segments,  nerve  roots 
and  vertebra  to  each  other  is  shown  in  the  accompanying 
diagram  from  Gowers. 

The  upper  limit  of  a  coarse  spinal  lesion  may  be  deter- 
mined in  three  ways  : 

1.  By  comparing  the  upper  limit  of  the  sensory  loss 
with  the  sensory  areas  supplied  by  the  several  spinal  seg- 
ments as  given  in  Figs.  28  and  29 ;  sometimes  the  limit  of 
anesthesia  is  made  especially  distinct  by  a  zone  of  hyperes- 
thesia immediately  above  it. 

2.  By  comparing  the  upward  limit  of  the  paralysis  and 
loss  of  faradic  irritability  with  the  table  on  the  next  page 
showing  the  relation  of  muscles  to  spinal  segments. 

3.  By  comparing  the  loss  of  reflexes  with  the  part  of  the 
same  table  showing  the  relation  of  reflexes  to  spinal  seg- 
ments. 

In  determining  the  lower  limit  of  the  lesion  it  is  obvious 
that  sensory  loss  and  paralysis  cannot  be  utilized  but  the 
good  condition  of  segments  below  the  lesion  will  usually 
be  indicated  by  the  absence  of  atrophy,  the  presence  of 
faradic  irritability  and  the  reflex  response  of  the  corre- 
sponding  muscles.     For  example,  in  a  case  of   gunshot 


Table  Modified  from  Gowers,  Showing  the  Approxi- 

MATE  Relation  of  Spinal   Segments  to 

Muscles  and  Reflexes. 


mastoid. 
Upper  neck 

muscles. 

Upper  part 

of  Trapezius 


Lower  neck 
muscles. 


Muscles.      Segments.  Muscles.  Segments. 

C   I  ]  Small  rotators  of  head.         C   i 
Sterno       f  Y 

2  )  Depressors  of  hvoid.  2 

3  Lev.  ang.  scapulae.  3 

4]  4 

>  Diaphragm. 

ISerratus. 
Flexors  of  elbow 
Supinators. 

)^        Extensors  of  wrist  and 
j  fingers. 

'  ^  Ext.  elbow. 

y  Flex,  wrist  and  fingers. 
Q  j  Pronators. 


Reflexes. 


Middle  part 
of  Trapezius 


Shoulder. 
Muscles. 


D   I  (  Intrinsic  muscles  of  hand.  D   i 


Lower  part 

of  Trapezius 

and  Dorsal 

muscles. 


Triceps-jerk.    1  — 

VWrist-j.  (ext.)  I  a 

Wrist-j.(flex.)|  g 


.  Intercostals. 


Abdominal  muscles. 


12 

L  I 


Lumbar 
muscles. 

Peronei. 
Flex,  of 

ankle. 
Ext.  of 

ankle. 


5 
S  I 


(Cremaster. 
Flexors  of  hip. 

I  Extensors  of  knee. 
[Adductors  of  hip. 

Ext.  and  abductors  of  hip. 
Flexors  of  knee. 
Intrinsic  muscles  of  foot. 

Perineal  and  anal  muscles. 


L   I 

2  ' 


3J 


S   iJ 


Palmar. 

Epigastric. 

Abdominal. 
Cremasteric. 
Knee-jerk. 

Gluteal. 
Heel-jerk. 


■  Plantar. 


4 

5 

Co. 


4 

5 

Co. 


Perineal,  anal 
and  vesical. 


LOCALIZATION    DIAGNOSIS.  IO9 

wound  of  the  cord  there  was  sensory  loss  up  to  the  line 
between  the  first  and  second  lumbar  areas ;  there  was 
paralysis  of  all  joints  of  both  lower  limbs  with  correspond- 
ing loss  of  faradic  irritability  and  reflexes.  This  indicated 
an  extensive  lesion  in  the  lumbar  enlargement  and  that 
the  second  lumbar  was  the  uppermost  segment  involved. 
But  the  anal  and  perineal  reflexes  were  lively  and  the 
faradic  irritability  of  the  perineal  muscles  was  retained ; 
there  was  complete  retention  of  urine  until  a  large  quantity 
had  accumulated  and  then  there  was  a  purely  reflex  evacu- 
ation. This  indicated  that  the  lower  sacral  segments  were 
not  involved.  Consulting  Fig.  16  it  will  be  seen  that  the 
damaged  portion  of  the  cord,  extending  from  the  second 
lumbar  to  the  second  sacral  segment  inclusive,  was  con- 
tained mainly  by  the  twelfth  dorsal  vertebra,  not  extend- 
ing as  high  as  the  upper  border  of  the  eleventh  or  as  low 
as  the  lower  border  of  the  first  lumbar.  An  operation  was 
performed  and  the  bullet  found  within  the  spinal  canal  just 
above  the  lower  border  of  the  eleventh  dorsal  vertebra. 

Cerebral  Localization. — The  cerebral  lesions  that  cause 
double  hemiplegia  or  paraplegia  act  in  precisely  the  same 
way  as  those  which  cause  hemiplegia,  the  only  difference 
being  that  both  sides  of  the  brain  are  affected  instead  of 
one,  and  they  are  localized  by  applying  the  same  princi- 
ples as  in  hemiplegia. 

The  history  of  the  onset  must  be  carefully  studied.  If 
paralysis  has  occurred  in  two  distinct  attacks,  first  on  one 
side  and  then  on  the  other,  the  symptoms  attributable  to 
each  must  be  considered  separately,  for  in  such  a  case 
there  are  two  lesions,  having  no  connection  except  that  of 
a  common  cause,  such  as  syphilis  or  arteriosclerosis. 

Assuming  that  a  single  lesion  has  caused  paralysis  on 
both  sides,  the  localizing  symptoms  may  be  arranged  as 
follows  : 


no  NERVOUS    AND    MENTAL    DISEASES. 


LOCALIZATION  DIAGNOSIS  IN  DOUBLE  HEMI- 
PLEGIA  OR   PARAPLEGIA   OF   INTRA- 
CRANIAL  ORIGIN. 

I.  Spastic  paralysis  of  both  legs,  perhaps  also  involving  the 
arms  but  to  a  lesser  degree,  has  its  onset  at  birth  or  in  in- 
fancy. Epilepsy,  delayed  acquisition  of  speech  or  intellec- 
tual defects  almost  invariably  present. 

Cerebral  Birth  Palsy  or  Infantile  Cerebral  Palsy ^  due 
to  bilateral  tneningeal  hemorrhage  or  cortical  throm- 
bosis. 
II.   Spastic  paralysis  of  both  legs  occurs  along  with  symptoms 
indicating  an  intracranial  tumor. 

Growth  near  the   Vertex.,  pressing-  on  both  paracentral 
lobules. 

III.  There  is  double  hemiplegia  along  with  paralysis  of  the  third 
or  fourth  nerve  on  either  side.  Hemianopia  may  be  pres- 
ent. Optic  neuritis  and  other  signs  of  a  tumor  likely  to  be 
present.  Lesion  of  both  Crura. 

IV.  Double  hemiplegia  is  accompanied  by  paralysis  of  the 
seventh,  sixth  or  motor  branch  of  the  fifth  nerve,  on  either 
side,  or  by  anesthesia  of  the  face.  Swallowing  and  articu- 
lation generally  impaired.  Hyperpyrexia  and  a  rapidly  fatal 
course  common  in  acute  lesions.     Bilateral  lesion  of  Pons. 

V.  Paralysis  on  both  sides  of  the  body  (perhaps  irregularly  dis- 
tributed) is  accompanied  by  paralysis  of  the  lips,  tongue, 
palate,  pharynx  and  laryiix.  Acute  lesions  rapidly  fatal. 
(See  Bulbar  Paralysis.)  Lesion  of  the  Medulla. 


PARALYSIS    OF    OCULAR    MUSCLES.  Ill 


PARALYSIS    OF   OCULAR   MUSCLES. 

The  paralysis  is  not  limited  to  the  associated  movements  of 
both  eyes  which  can  be  made  voluntarily  bv  normal  indi- 
viduals, such  as  convergence  or  conjugate  moveinent  to 
the  right  or  left,  but  when  the  eyes  are  tested  separately  a 
motion  which  is  not  separately  under  the  control  of  the  will 
is  found  to  be  lost  on  one  side  independently  of  the  action  of 
the  other.  Paralysis  of  the  levator  is  revealed  by  ptosis  ;  of 
the  external  muscles  of  the  eye-ball  by  limitation  of  move- 
ment in  the  direction  of  the  affected  muscle,  secondary 
deviation  of  the  sound  eye  and  diplopia ;  of  the  internal 
ocular  muscles  bv  the  absence  of  accommodation  or  of 
pupillary  action.  Spasm  simulating  ptosis,  spasmodic  stra- 
bismus or  spasm  of  the  muscle  of  accommodation  must  not 
be  mistaken  for  paralysis. 

A.  The  paralysis  is  caused  by  hemorrhage,  inflammation  or 
new  growth  within  the  orbit. 

B.  The  paralysis  is  not  caused  by  disease  within  the  orbit. 

1.  The  paralysis  is  congenital,  often  associated  with 
malformation  of  various  kinds  but  not  with  signs  of 
active  disease. 

Error  of  DeveIop?nent  of  nuclei^  nerve  trunks 
or  Jituscles. 

2.  The  paralysis  is  congenital  or  occurs  in  early  infancy, 
associated  with  globular  enlargement  of  the  cranium. 
Convulsions  and  other  paralyses  common. 

Hydrocephalus. 

3.  The  paralysis  occurs  at  birth  or  afterw^ard. 

a.  The  combination  of  other  symptoms,  especially 
hemiplegia,  headache,  dizziness,  vomiting  or 
mental  impairment,  with  the  ocular  paralysis  in- 
dicates the  existence  of  coarse  organic  disease 
within  the  cranium. 


112 


NERVOUS    AND    MENTAL    DISEASES. 


The  onset  of  symptoms  is  sudden  and 
§  Occurs  at  birth.     Hemiplegia,  diplegia  or 
monoplegia   accompanies  the    ocular    par- 
alysis.     Epilepsy  and  mental  defect  com- 
mon in  survivors. 

Cerebral  Birth  Palsy ^  generally  due  to 
meningeal  Hemorrhage. 


Fig.   17 


Rad.  anteriores 


Situation  of  the  Cranial  Nerves.     {From  Tyson,  after  Edinger.) 

Cranial  nerve  nuclei,  oblongata,  and  pons  represented  as  transparent.    Motor  nuclei, 
black  ;  sensitive  nuclei  red. 


§§   Immediately  follows  a  blow^  on  the  head. 
Damage  to  nerve  trunks  or  nuclei  by 
Concussion^!  Hemorrhage  or  Frac- 
ture. 
§§§   Is  not  related  to  injury  of  the  head. 

He7norrhage  or  Thrombosis  in  the  re- 
gion of  the  nuclei  or.,  very  rarely^ 
hemorrhage  into  nerve  sheath. 
Onset  of    cerebral  symptoms  acute  in  a  iom 
hours  to  a  vs^eek. 


PARALYSIS    OF    OCULAR    MUSCLES.  II3 

§  A  source  of  intracranial  infection  or  ir- 
ritation is  present,  e.  g.^  purulent  otitis 
media,  tuberculosis,  pneumonia,  epi- 
demic influence  or  insolation.  Onset 
marked  by  headache  and  fever,  often 
accompanied  by  vomiting.  General  hy- 
peresthesia exists  at  first,  but  is  soon  fol- 
lowed by  delirium  which  merges  into 
stupor  and  coma,  headache  persisting  as 
long  as  the  patient  can  answer  questions. 
Rigidity  of  the  neck  with  retraction  of 
the  head,  localized  twitching  and  general 
convulsions  are  common.  Other  paraly- 
ses may  occur.  Optic  neuritis,  rarely 
intense,  is  common  when  the  disease  is  at 
the  base,  rare  when  it  is  over  the  con- 
vexity. 

Meningitis^  possibly  cerebritis  or 
abscess. 
§§  The  eye-lids  and  temple  on  the  affected 
side  are  edematous  and  distended  by 
venous  blood  and  the  eye-ball  is  prom- 
inent. The  patient  is  depressed  by  an 
exhausting  disease  or  there  is  a  source 
of  infection.  Temperature  normal  or 
only  slightly  raised,  unless  meningitis 
also  exists. 

Thrombosis  of  Cavernous  Sinus. 

§§§  Ocular  paralysis   preceded  or  followed 

by  atrophic  paralysis  of  limbs  or  of  lips, 

tongue   and   throat.     No    sensory  loss. 

Onset  like  that  of  an  eruptive  fever. 

Polio-encephalitis^  acute  injlamma- 

tion  of  nuclei  analogous  to  polio- 

?nyelitis. 

§§§§   Onset   of    cerebral   symptoms   rapid    in 

a  person  who    gives    a    history   or    the 


10 


114  NERVOUS    AND    MENTAL,    DISEASES. 

signs  of  chronic  alcoholism.  Paralysis 
of  the  limbs  accompanied  by  tenderness 
of  muscles  and  nerves  and  sensory  loss 
(alcoholic  neuritis),  often  by  character- 
istic delirium,  usually,  but  not  always 
precedes  the  ocular  paralysis. 

Alcoholic  Polio-encephalitis. 
iii.   Onset  acute,  subacute  or  chronic.     A  source 
of  purulent  infection  present,  e.  g. ,  suppura- 
tive otitis  media,  infected  v\^ound  of  the  head, 
empyema  or  abscess,  in  any  part  of  the  body. 
Temperature  irregular,   usually  elevated,  but 
sometimes    depressed.     Rigors    followed    by 
fever  and  sweating  common.     Optic  neuritis 
frequent,  but   rarely  intense.     Duration  may 
be  short  or  very  long  w^ith  a  period  of  latency. 
Intracranial  Abscess. 
iv.   Onset  chronic. 

§  No  source  of  purulent  infection.  Personal 
or  family  predisposition  to  new  growths 
may  be  apparent.  Temperature  normal  or 
only  slightly  disturbed.  Headache  gen- 
erally intense,  often  accompanied  by  giddi- 
ness and  vomiting.  Optic  neuritis  in  four- 
fifths  of  all  cases,  usually  intense.  Pulse 
often  slow.  Course  long  and  mostly  pro- 
gressive. Toward  the  end  mental  failure 
tending  toward  stupor  and  coma. 

Intracranial    Tumor.,    ificluding  aneu- 
rism and  hydatid  cyst. 
§§   Patient  alcoholic  or  syphilitic.      Optic  neu- 
ritis absent  or  slight.     No  fever  or  slowness 
of  pulse.     There  may  be  spasm  or  paral- 
ysis in  the  domain  of  other  cranial  nerves, 
rarely  in  the  limbs.       Chronic  Meningitis. 
b.   Proof   of   the  existence  of    coarse  organic    intra- 
cranial disease  is  lacking,  but  there  is  evidence  of 
an  intoxication  or  infection. 


PARALYSIS    OF    OCULAR    MUSCLES.  II5 

i.  The  paralysis  is  limited  to  the  muscles  con- 
cerned in  light  reaction  and  accommodation. 
The  patient,  intentionally  or  by  accident,  is 
under  the  influence  of  atropia  or  a  drug  of 
similar  action, 
ii.  Syphilis  is  active,  as  shown  by  the  history  or 
the  presence  of  characteristic  symptoms. 

Syphilitic  Injlammation  of  nerves  or  nu- 
clei or  pressure  upon  tJiem  by  a  gumma. 
iii.  The  ocular  paralysis  follows  diphtheria  or, 
rarely,  comes  on  during  its  course.  Commonly 
limited  to  loss  of  accommodation  together  with 
paralysis  of  the  soft  palate  but  any  or  all  of 
the  external  ocular  muscles  may  be  affected 
and  the  muscles  of  the  limbs  may  show  a 
wasting  paralysis  with  loss  of  tendon  reflexes. 
In  severe  cases  there  is  a  corresponding  sen- 
sory loss.  Diphtheritic  Neuritis. 
iv.  The  ocular  paralysis  occurs  as  a  symptom  of 
influenza,  pneumonia,  scarlatina,  measles  or 
typhoid  fever  or  of  poisoning  by  metals,  pto- 
maines or  gases,  without  other  signs  of  men- 
ingitis. 

Probably  Injlammation  of  Nuclei.^  possibly 
Neuritis. 
§  History  of  exposure  to  lead.  Dark  line  at 
junction  of  gums  and  teeth.  Lead  often 
present  in  the  urine.  Characteristic  colic 
and  other  paralyses,  especially  of  the  exten- 
sors of  wrists  and  fingers,  almost  always 
precede  ocular  paralysis. 

Plumbic  Neuritis    or    degeneration    of 

nuclei. 

V.   Sugar  in   the  urine,  thirst,  excessive  appetite 

and  general  weakness  indicate  the  presence  of 

diabetes.  Diabetic  Neuritis. 

.  There   are   signs   of    degenerative  disease   of   the 


Il6  NERVOUS    AND    MENTAL    DISEASES. 

central  nervous  system.     Individual  muscles  sup- 
plied by  the  third   nerve  often  paralyzed   alone, 
indicating  disease  of  the  nuclei.     The  ocular  palsy 
is  often  transient  but  may  be  permanent  and  some- 
times progresses  to  complete  paralysis  of  all  the 
external  muscles  of  both  eyes,  accommodation  and 
contraction  of  the   pupil  usually  being  preserved. 
Optic   atrophy   and    the   Argyll-Robertson    pupil 
are  common.      The  ocular  paralysis  may  precede 
all  other  symptoms, 
i.   The    knee-jerks    are    absent.       A    history   of 
lightning  pains  in  the  legs  is  common,  also  of 
loss  of  virility  and  slight  difficulty  in  voiding 
or  retaining  the  urine.     The  patient  sways  on 
standing    with  eyes  closed    and    in   the    later 
stages   the   gait   is  ataxic.     Argyll-Robertson 
pupil  in  most  cases.  Tabes. 

ii.  Failure  of  judgment  and  memory,  often  com- 
bined with  monstrous  and  unsystematized  de- 
lusions of  grandeur,  accompanies  signs  of 
organic  disease,  among  which  inequality  of 
pupils  and  stumbling  speech  are  common. 

Paretic  Deinentia. 
iii.  Intention  tremor  with  nystagmus  or  scanning 
speech  is  associated  with  various  signs  of  scat- 
tered lesions,  such  as  isolated  paralyses,  con- 
traction of  the  visual  fields  with  impairment 
of  color  sense,  loss  of  smell,  nervous  deafness, 
etc.  Dissemhzated  Sclerosis. 

iv.   Ocular  paralysis  associated  with  spastic  para- 
plegia of  gradual  onset  accompanied  by  ataxia. 
No  sensory  loss.        Postero-lateral  Sclerosis. 
V.   Ocular  paralysis  associated  with  wasting  pa- 
ralysis  and  fine   fibrillary  twitching  in  other 
muscles. 
§   Wasting    paralysis    begins    in   muscles   of 
hand,  shoulder  or  upper  arm. 


PARALYSIS    OF    OCULAR    MUSCLES.  II7 

!   Spastic  weakness  of  legs.     Tendon  re- 
flexes of  paralyzed  muscles  exaggerated. 
Amyotrophic  Lateral  Sclerosis. 
!  !   No  weakness  of  legs  until  latest  stages. 
Tendon  reflexes  of  paralyzed   muscles 
abolished. 

Spinal  Muscular  Atrophy. 
§§   Wasting    paralysis    begins    in   muscles   of 
lips,  tongue,  pharynx  and  larynx,  interfer- 
ing with  speech  and  swallowing. 

Bulbar  Paralysis. 
vi.  Ocular  paralysis  associated  Avith  loss  of  pain 
and  temperature  sense  in  areas  where  touch 
is  retained,  together  with  paralysis  and  trophic 
disturbances  of  variable  and  irregular  distribu- 
tion. Syringomyelia. 

d.  There  is  no  evidence  of  coarse  organic  disease, 
infection  or  organic  degenerative  disease  of  the 
central  nervous  system.  The  ocular  paralysis  oc- 
curs periodically,  usually  associated  with  migraine 
or  severe  neuralgia,  at  first  completely  disappear- 
ing after  each  attack  but  tending  to  become  per- 
manent. 

Periodic  Ocular  Paralysis.      (^Migraine  Oph- 
thalmoplegique . ) 

e.  The  ocular  paralysis  is  a  complication  of  a  gen- 
eral nervous  condition  in  which  rapid  heart  action, 
enlargement  of  the  thyroid  gland  and  exophthalmos 
are  prominent  symptoms. 

Exophthalmic   Goitre. 

f .  The  ocular  paralysis  exists  alone  or  together  with 
facial  paralysis. 

i.  Muscles  of  one  eye  affected  after  exposure  of 
that  side  of  the  head  to  a  draft. 

'"'•Rheumatic''''    Ocular   Paralysis.,   dtie    to 
neuritis  and  analogous  to  the  ordinary 
form  of  facial  palsy. 


Il8  NERVOUS    AND    MENTAL    DISEASES. 

ii.   No  cause  can  be  found. 

Diagnosis  Jtecessarily  uncertain  but  in  most 
cases  a  symptom  of  Syphilis  or  the  first 
syjnptofn  of  a  degeneration  such  as  Tabes 
or  Paretic  Dem,entia. 
II.   The  movement  lost  is  one  of  the  associated  movements  of 
both  eyes  normally  under  control  of  the  vs^ill,  viz.,  conver- 
gence, divergence  or  motion  to  either   side  or   upward  or 
downw^ard.      When  either  eye  is  tested  alone  all  the  muscles 
may  act.      To  be  distinguished  from  spasm  of  the  muscles 
opposing  those  appearing  to  be  paralyzed,  although  an  error 
in  this  respect  might  not  affect  the  pathological  diagnosis. 

A.  The  combination  of  other  symptoms  with  the  ocular 
paralysis,  especially  of  hemiplegia,  headache,  dizziness, 
vomiting  or  mental  impairment,  indicates  the  existence 
of  coarse  organic  disease  within  the  cranium.  Ocular 
paralysis  generally  transitory. 

Diagnosis  to  be  made  as  in  Hemiplegia  or  as  in  /, 
B  of  this  table^  q.  v. 

B.  Proof  of  the  existence  of  coarse  organic  intracranial  dis- 
ease is  lacking  but  there  is  evidence  of  an  intoxication 
(alcohol,  opium,  chloral,  lead,  diabetes,  ptomaines)  or 
an  infection  (syphilis,  diphtheria,  influenza,  pneumonia, 
scarlatina,  typhoid  fever) . 

Infiammation  or  functional  i7npairm.ent  of  cortical 
centers^  subcortical  tracts  or  nuclei. 

C.  There  are  signs  of  degenerative  disease  of  the  central 
system.  Optic  atrophy  and  the  Argyll-Robertson  pupil 
are  common. 

Diagnosis  to  be  made  as  in  Optic  Atrophy  or  as  in 
/,  ^,  J,  c  of  this  table. 

D.  Signs  of  organic  disease,  intoxication  or  infection  absent. 
I .   There  is  weakness  and  lack  of  balance  of  the  ocular 

muscles  but  no  actual  paralysis.  Errors  of  refraction 
are  commonly  associated.  The  patient's  nervous 
energy  has  been  exhausted.  Disagreeable  sensations 
in  the  head  and  along  the  spine  which  shift  their 


PARALYSIS    OF    OCULAR    MUSCLES.  II9 

location  within  a  very  short  time,  irritability  and 
morbid  fears  are  common.  Neurasthenia. 

Ocular  paralysis  occurs  and  may  vary  or  disappear 
under  the  influence  of  emotion  or  direct  or  indirect 
suggestion.  History  and  other  symptoms  indicate  the 
presence  of  hysteria,  while  no  other  cause  can  be 
found.     Rare.  Hysteria. 

The  ocular  paralysis  is  a  complication  of  a  general 
nervous  disorder  in  which  rapid  heart  action,  en- 
largement of  the  thyroid  gland  and  exophthalmos  are 
prominent  symptoms.  Exophthalmic  Goitre. 

The  ocular  paralysis  exists  alone  and  no  cause  can  be 
fovmd. 

Diagnosis  necessarily  uncertain  but  in  most  cases 
a  symptom  of  Syphilis  or  the  Jirst  symptom  of 
'a  degeneration.^  such  as  Tabes  or  Paretic  De- 
mentia. 


I20  NERVOUS    AND    MENTAL    DISEASES. 


LOCALIZATION  DIAGNOSIS  IN  PARALYSIS  OF 
OCULAR   MUSCLES. 

The  nature  of  the  lesion  causing  ocular  paralysis  affords 
some  indication  of  its  situation.  Meningitis  and  syphilis 
are  especially  likely  to  damage  the  surface  of  the  brain 
and  the  nerve  trunks  at  the  base ;  they  rarely  attack  the 
nuclei.  Degenerative  diseases,  such  as  tabes,  spinal  mus- 
cular atrophy,  bulbar  paralysis,  and  the  acute  inflamma- 
tion of  alcoholism  or  poliomyelitis  attack  the  nuclei,  usually 
on  both  sides.  Paretic  dementia  may  cause  paralysis  of 
conjugate  movement  (inability  of  both  eyes  to  look  in  a 
certain  direction)  by  damage  to  the  cortex,  or  paralysis  of 
definite  muscles  by  damage  to  the  nuclei.  More  precise 
indications  are  given  by  the  distribution  of  the  paralysis, 
as  shown  in  the  following  table  : 

I.  The  paralysis  is  limited  to  the  muscles  of  one  eye.  Swell- 
ing and  venous  congestion  of  the  lids  and  protrusion  of  the 
eye-ball  appear  along  with  the  paralysis  or  soon  after  it. 
Optic  neuritis  or  atrophy  may  occur.  No  signs  of  disease 
within  the  cranium.  Lesion  within  the  Orbit. 

II.  All  the  muscles  supplied  by  the  third  nerve  are  paralyzed  or 
w^eakened  at  the  same  time.  Other  cranial  nerves  may  be 
involved.  The  pathological  condition  is  hemorrhage,  men- 
ingitis, syphilis  or  tumor. 

Lesion  at  the  Base  of  the  Brain.,  damaging  the  nerve 
trunk. 
A.   The   paralysis   of   the   third    nerve    is   accompanied   by 
hemiplegia  on  the  opposite  side,  with  or  w^ithout  corre- 
sponding hemianopia.  Lesion  of  the  Cms. 


LOCALIZATION    DIAGNOSIS.  121 

III.  The  paralysis  is  bilateral  and  may  be  limited  to  only  a  part 
of  the  muscles  supplied  by  the  third  and  fourth  nerves,  the 
others  retaining  their  function  or  becoming  paralyzed  at 
a  considerably  later  time.  The  pathological  condition  is 
usually  a  vascular  lesion,  an  intoxication,  acute  inflammation 
or  a  degeneration.  Lesion  of  the  Nuclei. 

IV.  The  external  rectus  of  one  eye  is  paralyzed,  the  motions  of 
the  other  eye  being  normal.  The  pathological  condition  is 
hemorrhage,  meningitis,  syphilis  or  tumor. 

Lesio7t  at  the  Base  of  the  Brain^  datnaging  the  nerve 
trunk. 
V.  The  external  rectus  of  one  eye  is  paralyzed  and  the  other  eye 
cannot  voluntarily  be  turned  inward.  Facial  paralysis  may 
occur  at  the  same  time,  or  paralysis  of  the  muscles  of  mas- 
tication, or  facial  anesthesia.  Nystagmus  is  common.  Sw^al- 
lowing  and  articulation  are  likely  to  be  impaired. 

Lesion  of  Nucleus  of  Sixth  Nerve. 
VI.  There  is  inability  to  look  in  a  certain  direction,  both  eyes 
being  affected  alike.  Usually  occurs  in  acute  cerebral 
lesions  along  vs^ith  hemiplegia,  the  eyes  and  head  being 
turned  away  from  the  paralyzed  side.  May  be  preceded  by 
spasm  in  which  the  eyes  and  head  are  turned  toward  the 
convulsed  (afterward  paralyzed)  limbs. 

Lesion  of  Frontal  Cortex  or  subcortical  tract. 


122 


NERVOUS    AND    MENTAL    DISEASES. 


Fig.  i8. 


6^ 


Simplified  Drawing  of  the  Peripheral  Distribution  of  the  Facial  Nerve- 
{Froni  Tyson, after  Sahli.) 


FACIAL    PARALYSIS.  1 23 


FACIAL   PARALYSIS. 

Muscles  supplied  by  all  branches  of  the  seventh  nerve 
paralyzed  with  wasting  and  loss  of  faradic  irritability  in  all 
but  the  mildest  cases.  ^ 

I.   Paralysis  follows  external  injury. 

A.  Injury   occurs    at    birth,    forceps    having   pressed   upon 
nerve  near  its  exit  from  the  skull.       Pressure  Netiritis. 

B.  Paralysis  follows  wounds  or  operations  about  the  ramus 
of  the  jaw. 

1.  Occurs  immediately. 

Section  or  Crushing  of  Nerve. 

2.  Occurs  after  a  few  days.  Neuritis. 

C.  Follows  fracture  of  the  skull,  nervous  deafness  usually 

occurring  at  the  same  time. 

1.  Occurs  immediately. 

Section  or  Crushing  of  Nerve. 

2.  Occurs  after  a  few  days.  Neuritis. 
II.   No  external  injury. 

A.   Onset  sudden,  in  a  few  moments. 

1.  Limbs   on   opposite   side   paralyzed    (crossed   hemi- 
plegia) or  sixth  nerve  on  same  side. 

Hemorrhage  or  Thrombosis  of  Pons. 

2.  Nervous  deafness  and  vertigo  occur  at  the  same  time. 

Hemorrhage  pressing  on  Seventh  and 
Eighth  Nerves. 

3.  Taste  lost  in  anterior  two-thirds  of  tongue  on  same  side. 
Hemorrhage    into  Facial    Canal  above   origin   of 

Chorda  Pympani. 

4.  Face  alone  affected. 

Hemorrhage  into  Canal  below  origin  of  Chorda. 

'  Paralysis  of  the  lower  part  of  the  face  without  wasting  or  loss  of 
faradic  irritability  is  included  under  the  head  of  Monoplegia. 


124  NERVOUS    AND    MENTAL    DISEASES. 

B.  Onset  gradual  but  acute,  in  a  few  hours  to  a  few  days. 

1 .  A  source  of  intracranial  infection  or  irritation  is 
present.  Onset  of  disease  marked  by  headache  and 
fever,  often  accompanied  by  vomiting.  General 
hyperesthesia  exists  at  first  and  is  soon  followed  by 
delirium  vs^hich  in  severe  cases  merges  into  stupor 
and  coma,  headache  persisting  as  long  as  the  patient 
can  answer  questions.  Retraction  of  the  head,  local- 
ized twitching  and  general  convulsions  are  common. 
Other  paralyses  may  occur,  especially  in  the  ocular 
muscles.  Optic  neuritis,  rarely  intense,  is  common 
in  the  more  protracted  cases.  Meningitis. 

2.  Svippurative  otitis  media  present;  no  other  cause. 
No  other  paralysis  or  spasm ;    mind  clear. 

Inflammation  of  Nerve  Trunk. 

3.  Face  has  been  exposed  to  cold  especially  in  a  w^ind  or 
draught ;  no  other  cause.  Eye  muscles  on  the  same 
side  very  rarely  paralyzed.  The  most  common  form  ; 
often  called  rheumatic. 

Inflammation  of  Nerve  Trunk. 

C.  Onset  of  disease  chronic. 

I .   Accompanied  by  headache  and  often  by  vomiting. 

a.  Optic  neuritis  present,  generally  intense.  Other 
cranial  nerves  affected,  especially  the  eighth  and 
sixth.     Convulsions  may  occur.     Pulse  often  slow. 

Intracranial  Tumor.,  Aneurism  or  Cyst. 

b.  Patient  alcoholic  or  syphilitic.  Optic  neuritis  ab- 
sent or  slight.  No  fever  or  slowness  of  pulse. 
There  may  be  paralysis  or  spasm  in  the  domain  of 
other  cranial  nerves,  rarely  in  the  limbs.  Nerv- 
ous deafness  and  vertigo  generally  present. 

Chronic  Meningitis . 

c.  Intention  tremor  is  present  together  with  nystag- 
mus, scanning  speech  or  other  evidence  of  scat- 
tered lesions.  Dissem,inated  Sclerosis. 

d.  Absence  of  knee-jerk  and  other  symptoms  indi- 
cates tabes.     Rare.  Tabes. 


BULBAR    AND    PSEUDO-BULBAR    PARALYSIS.  1 25 


BULBAR   AND    PSEUDO-BULBAR   PARALYSIS. 

Two  or  more  of  the  following  organs  are  paralyzed  : 
lips,  tongue,  palate,  pharynx  and  larynx. 

I,  Onset  sudden  in  a  single  attack.  Paralysis  commonly 
bilateral,  rarely  unilateral.  Palatal,  pharyngeal  and  laryn- 
geal reflexes  usually  impaired.  Atrophy  and  reaction  of 
degeneration  may  occur  in  affected  muscles. 

Apoplectiform  Bulbar  Paralysis. 

A.  Not  immediately  fatal. 

Thrombosis  of  Alediilla  Oblo7igata  or.^  very  rarely.^  Hem- 
orrhage or  Ernbolistn. 

B.  Immediately  fatal. 

Hemorrhage  or  Throtnbosis  of  Medulla.^  very  rarely 
Embolis7n. 
II.  Onset  sudden  but  in  two  attacks,  paralysis  of  the  muscles 
supplied  from  the  medulla  not  occurring  until  the  second 
attack  and  the  larynx  usually  escaping.  Double  hemiplegia 
or  other  symptoins  show  that  each  hemisphere  is  involved. 
Nutrition  and  electrical  reactions  of  the  paralyzed  muscles 
not  affected.      Throat  reflexes  preserved.     Very  rare. 

Pseudo-bulbar  Paralysis  dice  to  vascular  lesion  in  each 
hemisphere. 
III.   Onset  acute,   in  a  few  hours  to  a  few  days.     The  affected 
muscles  waste  and  lose  faradic  irritability.     The  throat  re- 
flexes are  lost.     There    is  usually  also  atrophic  paralysis  of 
the  eye  muscles,  face  or  limbs. 

A.  The  paralysis  follows  or  possibly  accompanies  diphtheria, 
beginning  in  the  ciliary  muscle  and  palate. 

Diphtheritic  Bulbar  Paralysis. 

B.  Paralysis   secondary  to  influenza,  typhoid  fever  or  other 

infectious  or  toxic  disease.     Very  rare. 

Neuritis    or.,    possibly.^    Infammation    of    Bulbar 
Nuclei. 


126  NERVOUS    AND    MENTAL    DISEASES. 

C.  Paralysis  is  part  of  the  primary  disease  whose  onset  is 
attended  by  headache,  fever  and  perhaps  vomiting  or 
convulsions.      Very  rare. 

Injlammatiojt  of  Bulbar  Nuclei^  analogous  to  folio- 
myelitis. 
IV.    Onset  generally  chronic,  sometimes  acute  or  subacute. 

A.  There  is  disease  in  the  vipper  part  of  the  neck  capable  of 
affecting  the  ninth,  tenth,  eleventh  and  twelfth  nerves  at 
their  exit  from  the  skull,  e.  g,^  tumors,  cellulitis,  ver- 
tebral caries,  wounds,  etc.  No  signs  of  intracranial 
disease.  JVetiritis. 

B.  No  disease  of  neck.    Signs  of  intracranial  disease  present. 

1.  Paralysis  unilateral,  at  least  at  first.  Lips  usually 
escape.  Headache,  vomiting  and  mental  dullness 
common. 

a.  Optic  neuritis  present,  often  intense.      Pulse  often 
slow.     Tumor  or  Aneurism  pressing  on  medulla. 

b.  Syphilis     active ;     headache    chiefly     nocturnal. 
Optic  neuritis  absent  or  of  slight  intensity. 

Syphilitic  Meningitis. 

2.  Onset  always  slow,  in  an  adult.  Paralysis  bilateral 
from  the  start,  beginning  in  the  tongue,  involving 
the  lips  and  tending  to  spread  to  the  palate,  larynx 
and  pharynx.  Headache  and  optic  neuritis  absent 
but  optic  atrophy  may  occur.  Paralyzed  muscles 
often  waste  and  show  altered  galvanic  reactions  even 
while  retaining  faradic  irritability.  Palatal,  pharyn- 
geal and  laryngeal  reflexes  usually  lost.  May  exist 
alone,  but  the  possibility  of  its  being  only  part  of  a 
widespread  degeneration,  such  as  spinal  muscular 
atrophy,  amyotrophic  lateral  sclerosis,  tabes,  dis- 
seminated sclerosis  or  paretic  dementia,  should 
always  be  carefully  considered. 

Typical  Bulbar  Paralysis,  due  to  degeneration 
of  nuclei. 

3.  Onset  acute  or  subacute,  usually  in  a  young  person. 
Muscles  excessively  fatigued  when  used,  but  recover 


BULBAR    AND    PSEUDO-BULBAR    PARALYSIS.  1 27 

temporarily  after  rest.  Electrical  reactions  retained 
but  may  be  quickly  exhausted  by  repetition  of  test. 
No  reaction  of  degeneration,  atrophy  or  sensory 
symptoms.  May  extend  to  masticatory,  facial  or 
ocular  muscles.  Symptoms  may  vary  greatly  from 
day  to  day.  Paralysis  of  respiration  or  swallowing 
may  occur,  but  recovery  is  possible. 

Asthenic  Bulbar  Paralysis^  no  anatomical  basis 
known. 


128  NERVOUS    AND    MENTAL    DISEASES. 


LARYNGEAL   PARALYSIS. 

Paralysis  of  one  or  more  laryngeal  muscles  without  in- 
volvement of  lips,  tongue,  palate  or  pharynx  and  without 
other  indication  of  organic  intracranial  disease. 

I.  The  neck  or  mediastinum  is  so  diseased  as  to  damage  one 
or  both  pneumogastric  nerves  or  their  laryngeal  branches, 
e.  g.^  stab  wound,  operation,  goitre,  enlarged  glands,  tumor, 
aneurism,  cellulitis,  etc. 

A .  The  vocal  cords  move  normally  in  breathing  but  remain 
lax  on  phonation,  the  glottis  forming  a  wavy  line. 
Food  enters  the  larynx  because  the  epiglottis  does  not 
properly  cover  it.  Upper  part  of  larynx  more  or  less 
anesthetic.     Very  rare. 

Bilateral  lesion  of  Superior  Laryngeal  Nerves. 

B.  One  or  both  cords  immovable  in  cadaveric  position  (be- 
tween abduction  and  adduction).  Breathing  not  im- 
peded. Phonation  and  explosive  cough  equally  difficult 
or  (in  bilateral  lesion)  impossible. 

I.   Heai-t  action  disturbed;    pulse  rapid.      Respiration 
may  be  slow.     Vomiting  may  occur. 

Lesio72  of  Trunk  of  Pneumogastric. 
2.  Pulse  and  respiration  not  affected. 

Lesion    of    one    or    both    Recurrent    Laryngeal 
Nerves. 

C.  Vocal  cords  can  be  adducted  in  phonation  but  only  partly 
separated  in  inspiration.  Breathing  stridulous,  espe- 
cially during  sleep. 

Partial  lesion  of  Recurrent  Nerves. 

II.   There  is  no  disease  in  the  neck  or  mediastinum,    but  the 

larynx   is   directly  injured  by  the   swallowing  of   injurious 

substances,  by  pressure  from  a  lodged  bolus,  or  from  adja- 


LARYNGEAL    PARALYSIS.  1 29 

cent  growths,  by  syphilitic  or  catarrhal   inflammation,  ex- 
cessive fatigue  or  the  like. 

Non-nervous  Laryngeal  Paralysis. 
III.  No  nerve  lesion  or  adequate  local  cause  can  be  found. 

A.  An  emotional  cause  can  be  traced  and  symptoms  may 
vary  much  with  emotional  changes.  History  of  hyster- 
ical attacks  common  and  various  other  signs  of  hysteria 
may  be  present.     Paralysis  always  bilateral. 

1 .  Voice  is  reduced  to  a  whisper.  Vocal  cords  do  not 
approach  on  attempted  phonation  but  move  normally 
in  breathing  and  approach  perfectly  in  explosive 
coughing  or  sneezing.  May  precede  or  follow  hys- 
terical mutism. 

Hysterical  Aphonia  due  to  paralysis  of  adductors. 

2.  Voice  not  impaired.  Inspiration  stridulous  ;  expira- 
tion normal.     Very  rare. 

Hysterical  Paralysis  of  Abductors. 

B.  No  cause  can  be  found.     Paralysis  sometimes  vinilateral. 

Probably  the  frst  sympto7n  of  bulbar  paralysis  or 
of  a  widespread  degeneratiott^  such  as  spinal 
musctilar  atrophy^  amyotrophic  lateral  sclerosis^ 
tabes^  disseminated  sclerosis  or  paretic  dementia. 


11 


130  NERVOUS    AND    MENTAL    DISEASES. 


PARALYSIS    OF   PARTIAL   OR   IRREGULAR 
EXTENT. 

I.  The  paralysis  appears  only  on  attempting  certain  coordinated 
movements  \vhich  have  been  performed  to  great  excess  in 
the  patient's  occupation,  such  as  writing,  telegraphing, 
playing  a  inusical  instrument,  etc. 

Paralytic  form  of  Writer's  Cramp  or  other  Occupation 
Neurosis. 
II.   All  motions  requiring  the  action  of  the  paralyzed  muscles 
equally  affected. 

A.  Onset  acute,  in  a  fev\^  hours  to  a  few^  days,  resembling 
that  of  an  eruptive  fever.  Paralyzed  muscles  waste  and 
lose  faradic  irritability.  No  sensory  loss.  Rheumatoid 
pains  of  onset  usually  quickly  subside  but  may  persist. 
Most  cases  in  later  infancy ;  six-sevenths  of  all  cases 
under  ten  years  of  age.  Poliomyelitis. 

B.  Onset  acute  or  subacute,  very  rarely  chronic.  Paralysis 
affects  muscle  groups  supplied  by  spinal  nerves  or  plex- 
uses and  is  accompanied  or  soon  followed  by  more  or 
less  sensory  loss  in  corresponding  areas  (Figs.  8  to  11). 
Affected  inuscles  waste  and  lose  their  tendon  reflexes  and 
faradic  irritability.  Numb,  tingling  or  burning  pain  in  the 
affected  area  w^ith  tenderness  of  the  muscles  and  often  of 
the  nerve  trunks.     Skin  often  edematous  and  glossy. 

I .   Paralysis,  pain  and  sensory  loss  in  the  area  supplied 
by  a  single  spinal  nerve. 

a.  The  apparent  cause  is  a  wound,  pressure  on  the 
nerve  trunk,  exposure,  infectious  or  toxic  disease 
or  the  extension  of  adjacent  inflammation. 

Neuritis. 

b.  No  traumatic,  infectious  or  toxic  cause  apparent. 
Nodular  swelling  can  be  felt  in  the  course  of  the 
nerve.  Neuroma. 


PARALYSIS    OF    PARTIAL    OR    IRREGULAR    EXTENT.     I31 

2.  Symptoms    in    the    area    supplied    by  the    brachial, 
lumbar  or  sacral  plexvis  of  one  side. 

a.  Symptoms  in  the  arm  with  severe  pain,  greatly 
increased  by  movement,  in  the  plexus  itself  as  well 
as  in  the  arm.  Wounds  or  contusions  affecting 
the  plexus,  forcible  retraction  of  the  shoulder, 
gout,  rheumatism,  exposure  and  (in  the  new-born) 
obstetrical  manipulations  are  the  most  common 
causes. 

i.  Paralysis  of  deltoid,  flexors  of  elbow,  supina- 
tors and  often  the  spinati.  Pain  and  sensory 
loss  in  shoulder  and  outer  side  of  arm. 

Neuritis    in     upper    part    of  plexus    or, 
rarely,  in  jifth  and  sixth  cervical  roots. 
ii.   Paralysis  in  triceps,  forearm  muscles  and  hand 
muscles.     Pain  and  sensory  loss  in  hand,  fore- 
arm and  inner  side  of  arm. 

Neuritis  ift  lower  part  of  plexus  or, 
rarely,  in  seve7tth  and  eighth  cervical 
and  frst  dorsal  roots. 

b.  Paralysis  of  flexors  of  hip,  adductors  of  thigh  and 
extensors  of  knee.  Pain  and  sensory  loss  in  lower 
part  of  abdomen,  front  and  sides  of  thigh  and 
inner  side  of  leg  and  foot.  New  growths  in 
abdomen,  caries  of  vertebrae  and  ascending  infec- 
tion the  common  causes. 

Neuritis  of  lumbar  plexus  or  roots. 

c.  Paralysis  of  flexors  and  outward  rotators  of  thigh, 
flexors  of  knee  and  muscles  moving  the  foot  and 
toes.  Pain  and  sensory  loss  in  back  of  thigh  and 
all  of  leg  and  foot  except  inner  side.  Pelvic 
growths  and  inflammation,  parturition  and  ascend- 
ing infection  the  common  causes. 

Netiritis  of  sacral  plexus. 

3.  Symptoms  in  the  areas  of  a  number  of  spinal  nerves 
on  both  sides,  especially  the  external  popliteal  and 
musculo-spiral  nerves.      Alcoholism  is  the  most  com- 


132  NERVOUS    AND    MENTAL    DISEASES. 

mon  cavise ;  other  causes  are  pyemia,  diphtheria  and 
other  infectious  diseases,  metalHc  poisons,  exposure 
and  ever-exertion.  Multiple  Neuritis. 

C.  Onset  of  disease  chronic  (except  very  rarely  in  paral- 
ysis agitans  when  it  follows  a  nervous  shock),  but  some 
symptoms,  including  paralysis,  may  come  on  rapidly, 
especially  in  disseminated  sclerosis. 

1 .  Paralysis  follows  tremor  which  begins  usually  in  one 
hand  and  gradually  spreads.  Voluntary  motion  is 
not  entirely  lost,  but  becomes  more  and  more  diffi- 
cult. The  face  becomes  expressionless ;  the  head 
and  shoulders  are  bent  forward,  the  elbows,  hips  and 
knees  are  slightly  flexed  and  the  hands  are  held  in  the 
"  pill-rolling  "  position  by  a  tonic  spasm  mainly  affect- 
ing the  flexor  muscles  (Fig.  20).  The  tremor  usually 
persists  during  rest,  but  ceases  temporarily  during  at- 
tempts to  arrest  it  or  to  use  the  hand ;  in  rare  cases  it 
is  entirely  absent  and  the  diagnosis  must  be  made 
from  the  weakness  and  the  characteristic  posture. 
Tendon  reflexes  normal.  No  sensory  loss  or  severe 
pain,  but  much  distress  and  unrest.  No  positive 
signs  of  organic  disease.  Patient  in  second  half  of 
life.  Paralysis  Ag'itans. 

2.  There  is  intention  tremor  (well  seen  when  the  patient 
attempts  to  drink)  which  is  generally  associated  with 
nystagmus,  scanning  speech  or  other  signs  of  mul- 
tiple lesions.  The  paralysis  may  begin  in  individual 
muscles  or  in  muscle  groups,  varying  greatly  in  situ- 
ation in  different  cases.  The  affected  muscles  may 
waste  and  lose  faradic  irritability,  but  as  a  rule  they 
do  not.  Tendon  reflexes  generally  exaggerated.  Be- 
gins during  first  half  of  life. 

Disseminated  Sclerosis. 

3.  The  paralysis  is  preceded  by  progressive  dementia, 
often  accompanied  by  delusions  of  grandeur,  stum- 
bling speech,  facial  twitching  and  pupillary  changes. 
A  disease  of  middle  life.  Paretic  Dementia. 


PARALYSIS    OF    PARTIAL    OR    IRREGULAR    EXTENT.     I33 

4.  Onset  of  paralysis  always  gradual  and  slow,  in  months 
or  years.  The  paralyzed  muscles  slowly  waste  and 
lose  faradic  irritability. 

a.   Atrophic    paralysis    begins    in    an  adult    patient, 
usually  in  the  hand  muscles,  deltoid  or  upper  arm 
muscles  and  after  spreading  more  or  less  to  others 
on  the  same  side  commonly  attacks  the  other  side 
in  the  same  order.     Fibrillation  is  common.      Re- 
action of   degeneration  may  occur  in  the  cases  of 
more    rapid    onset    but    not    in    the  slower  ones. 
The  muscles  are  never  enlarged  and  similar  cases 
are  very  seldom  found  in  the  same  family. 
i.   There  is  loss  of  pain  and  teinperature  senses, 
often  of  greater  extent  than  the  atrophic  pa- 
ralysis, with  retention  of  touch  sense   in  the 
same  area.      Other    trophic    changes    such   as 
glossy  or  thick  and  horny  skin,  whitlow,  ulcera- 
tions, gangrene  or  degeneration  of  joints  may 
occur.     There  may  also  be  a  spastic  weakness 
of  the  legs  without  wasting. 

Syringomyelia . 
ii.   There  is  no  sensory  loss  and   no  other  trophic 
syn:iptom  than  muscular  atrophy. 
§   The  atrophic  paralysis  in  the  upper  part  of 
the  body  is  accompanied  by  spastic  weak- 
ness   of    the    legs    without  wasting.      The 
tendon    reflexes    are    exaggerated    in    both 
arms  and  legs. 

Ajnyotrophic  Lateral  Sclerosis. 

§§   Lower  limbs  not  affected  until  late  in  the 

disease  when  their  muscles  are  wasted  and 

flabby.     Tendon   reflexes    of   the    affected 

muscles  diminished  or  lost. 

Spinal  Muscular  Atrophy. 
b.   Atrophic  paralysis  begins  in  childhood  in  the  dis- 
tribution of  the  peroneal  nerves,  causing  talipes 
equino varus.      The  disease  slowly  extends  to  the 


134 


NERVOUS    AND    MENTAL    DISEASES. 


muscles  of  the  calves  and  thighs,  and  some  years 
from  the  onset  may  involve  the  upper  extremities 
(beginning  in  the  intrinsic  muscles  of  the  hands) 
and  the  trunk.      Fibrillation  is  common.      Sensory 

Fig.  19. 


Mode  of  Rising  from  the  Ground  in  Pseddo-hypertrophic  Paralysis. 
{From  Cowers.) 

loss     may  be    observed.      Other    cases    generally 
occur  in  the  same  family. 

Progressive  Neural  Muscular  Atrophy.   (Also 
called     Peroneal     Porm,      Charcot-Marie 
Type.) 
c.   Paralysis  begins  elsewhere  than  in  hand  muscles, 


PARALYSIS    OF    PARTIAL    OR    IRREGULAR    EXTENT,     I35 

deltoid  or  muscles  supplied  by  the  peroneal  nerves. 
No  fibrillation.  No  reaction  of  degeneration,  gal- 
vanic and  faradic  irritability  diminishing  together. 
Other  cases  generally  occur  in  the  same  family. 

Idiopathic  Muscular  Atrophy. 
i.   Some  of  the  v^eakened  muscles  are  enlarged, 
usually  the  calves,  infraspinati,  quadriceps  ex- 
tensors, glutei  or  lumbar  muscles.     Onset  usu- 
ally in  childhood  (Fig.  19). 

Pseudo-hypertrophic  Musctilar  Atrophy. 
ii.  None  of  the  weakened  muscles  is  enlarged. 
Disease  begins  in  childhood,  youth  or  early 
adult  life  and  usually  first  attacks  the  biceps, 
triceps,  pectoral,  latissimus,  face,  extensors  of 
knee  or  flexors  of  hip. 

Sitnple  Idiopathic  Muscular  Atrophy. 


136  NERVOUS    AND    MENTAL    DISEASES. 


ATAXIA. 

The  patient  is  unable  to  stand  or  walk  steadily,  not  on 
account  of  weakness  alone,  but  because  of  incoordination 
of  muscular  action.  There  may  also  be  disordered  move- 
ment in  the  trunk  and  arms. 

I.  A  reeling  gait  and  the  associated  symptoms,  such  as  head- 
ache, vomiting,  optic  neuritis,  paralysis  in  the  domain  of 
the  cranial  nerves  or  hemiplegia,  indicate  coarse  intracranial 
disease  directly  or  indirectly  affecting  the  cerebellum  or  the 
region  of  the  qiiadrigeminal  bodies.  The  ataxia  is  not 
greatly  increased  by  closing  the  eyes. 

A.  Onset  of  symptoms  sudden  or  very  rapid,  usually  with 
loss  or  disturbance  of  consciousness.  The  arteries  are 
atheromatous  or  syphilitic  or  there  is  endocarditis.  No 
signs  of  suppuration. 

Hemoi-rhage^   Thrombosis  or  Embolism. 

B.  Onset  rapid  or  slow.  There  is  a  source  of  purulent  in- 
fection, e.^.,  an  infected  wound  of  the  scalp  or  cranium 
(especially  compound  fracture),  otitis  media,  empyema 
or  abscess  in  any  part  of  the  body.  Rigors  followed 
by  fever  and  sweating  common.  Temperature  irregular, 
mostly  elevated  but  sometimes  depressed.  Duration 
may  be  short  or  it  may  be  long  with  a  period  of  latency. 
Optic  neuritis  is  common  but  is  rarely  intense. 

Abscess. 

C.  Onset  chronic.  No  source  of  infection  but  a  personal 
or  family  predisposition  to  new  growths  may  be  ap- 
parent. Temperature  runs  a  normal  or  nearly  normal 
course.  Headache  generally  intense,  often  accompanied 
by  vertigo  and  vomiting.  Progressive  mental  failure 
occurs  toward  the  end.     Optic  neuritis  is  the  most  char- 


ATAXIA.  137 

acteristic  symptom ;    it  is   present   in  four-fifths   of    all 

cases  and  is  usually  intense.      Course   long  and  mostly 

progressive.  Tumor. 

II.   The   associated  symptoms,    such  as    absence  of    knee-jerk, 

slight    urinary     difficulty,    Argyll-Robertson    pupil,     optic 

atrophy,  lightning  pains,  nystagmus,  stumbling  or  scanning 

speech,  or  mental  impairment  of  the  paretic  type,  are  of  slow 

onset  and  indicate  a  degenerative  disease  affecting  the  spinal 

cord  or  both  cord  and  brain. 

A.  The  ataxia  of  gait  and  station  is  greatly  increased  by 
closing  the  eyes.  The  knee-jerks  are  absent  except  in 
rare  cases  in  which  advanced  optic  atrophy  is  an  early 
symptom.  A  history  of  lightning  pains  in  the  legs  is 
common,  also  of  loss  of  virility,  slight  urinary  difficulty 
ami  ptosis  or  diplopia.  Argyll-Robertson  pupil  in 
most  cases.  Tabes. 

B.  A  jerky  or  reeling  gait  begins  in  childhood  or  youth  in 
members  of  certain  predisposed  families  and  is  sooner 
or  later  accompanied  by  nystagmus,  stumbling  or  blurred 
speech  and  incoordination  of  neck  and  arm  muscles. 
Knee-jerks  generally  but  not  always  absent,  in  rare 
cases  increased.  Paralysis  and  corresponding  deformi- 
ties may  occur,  especially  in  the  later  stages. 

Hereditary  Ataxia  (^Friedreich's  Disease^. 

C.  Weakness  of  legs  and  ataxia  of  gait  and  station  begin  in 
adult  life  and  gradually  increase.  Knee-jerks  and  other 
tendon  reflexes  almost  alw^ays  increased,  very  rarely 
lost.  Lightning  pains  very  rare.  Slight  difficulty  of 
articulation  common.  Ataxic  Paraplegia. 

D.  Intention  tremor  with  nystagmus  or  scanning  speech  is 
associated  \vith  various  signs  of  scattered  lesions,  such 
as  isolated  paralyses,  contraction  of  the  visual  fields  with 
impairment  of  color  sense,  loss  of  smell,  nervous  deaf- 
ness, etc.      Knee-jerks  generally  exaggerated. 

Disseminated  sclerosis. 

E.  Failure  of  judgment  and  memory,  often  combined  with 
monstrous   and  unsystematized  delusions   of    grandeur, 

12 


138  NERVOUS    AND    MENTAL    DISEASES. 

accompanies    signs  of    organic    disease,    among    which 

inequality    of    pupils,    facial  twitching    and  stumbling 

speech  are  common.  Paretic  Dementia. 

III.   The  associated  symptoms  (such  as   paralysis,  wasting,  loss 

of    faradic   irritability,   tenderness  of    muscles  and    nerves, 

numb  stinging  pain  and  some   sensory  loss,  chiefly  in  the 

distribution  of  the  external  popliteal  or  external  popliteal  and 

musculo-spiral  nerves),  together  with  evidence  of  a  toxic  in- 

I  fluence,  indicate  multiple  neuritis.     Knee-jerk  lost  except  in 

the  rarest  cases.     Argyll-Robertson  pupil  absent.     Onset  of 

ataxia  usually  acute  or  subacute,  always  more  rapid  than  in 

the   average   case   of  tabes.      Other  symptoms  may  not  be 

marked. 

A.  History  of  prolonged  alcoholic  excess.  Various  signs 
of  alcoholism  may  be  present.  Pain  a  prominent  symp- 
tom. Alcoholic  Neuritis. 

B.  The  ataxia  is  preceded  by  diphtheria.  Onset  of  neuritis 
marked  by  loss  of  ocular  accommodation  and  paralysis 
of  the  palate.     Pain  absent  or  slight. 

Diphtheritic  Neuritis. 

C.  History  of  acute  or  chronic  poisoning  by  arsenic,  or 
arsenic  is  found  in  the  urine.  Both  arms  and  legs  usually 
affected.  Pain  a  prominent  symptom.  Herpes  zoster 
common.  Arsenical  Neuritis. 

D.  The  ataxic  form  of  neuritis  may  sometimes  be  due  to 
various  acute  infectious  diseases,  malaria,  septicemia, 
diabetes,  beri-beri  or  leprosy. 

IV.  There  is  no  evidence  of  organic  disease.  The  ataxia  ap- 
pears first  after  an  emotional  disturbance  and  may  increase  or 
diminish  in  correspondence  with  emotional  changes  or  sug- 
gestion. It  may  exist  in  any  degree  and  sometimes  pre- 
vents either  standing  or  sitting  (astasia-abasia) .  Various 
signs  of  hysteria  may  be  present.  Hysterical  Ataxia. 


TREMOR.  139 


TREMOR. 

I.  The  tremor  is  due  to  emotion,  exposure  to  cold  or  extreme 
fatigue  in  a  healthy  person.  It  is  fine ;  rate  about  10  per 
second.  Physiological  Tremor. 

II.  The  tremor  is  an  expression  of  the  weakness  of  an  exhaust- 
ing disease,  such  as  typhoid  fever,  or  of  neurasthenia.  It  is 
fine  and  rapid  and  ceases  during  rest.        Asthenic  Tremor. 

III.  The  tremor  is  due  to  poisoning  by  alcohol,  mercury,  lead, 
arsenic,  opium,  chloral,  tea,  coffee  or  tobacco. 

Toxic  Tremor. 

IV.  The  tremor  is  a  symptom  of  organic  disease  of  the  nervous 
system,  but  is  of  slight  diagnostic  importance  compared  with 
other  symptoms,  as  in  hemiplegia,  cerebral  tumor  or  abscess, 
cerebellar  disease,  paretic  dementia,  tabes,  hereditary  ataxia, 
etc. 

Diagnosis  as  in  Hemiplegia^  Optic  Neuritis.,  Head- 
ache., Ataxia.,  etc. 
V.   Tremor  is  a  prominent  and  important  symptom. 

A.  The  tremor  begins  after  forty  years  of  age,  usually  in 
one  hand,  rarely  in  one  leg  and  slowly  extends  to  the 
other  limb  on  the  same  side  and  then  to  the  limbs  on  the 
opposite  side.  Its  rate  is  five  to  seven  oscillations  a 
second  and  the  range  is  generally  small.  As  a  rule  it 
continues  during  rest  and  is  lessened  or  stopped  by 
effort ;  rarely,  in  an  early  stage,  it  is  elicited  by  effort. 
Following  the  tremor,  beginning  in  the  same  part  and 
spreading  in  the  same  order,  muscular  weakness  and 
rigidity  appear,  the  muscles,  especially  the  flexors,  grad- 
ually contracting  so  as  to  cause  a  characteristic  posture 
with  absence  of  facial  expression.  The  hands  assume 
the  "pill-rolling"  position;  the  knees,  hips,  wrists, 
elbows  and  shoulders,  are  somewhat  flexed ;   the  head 


140  NERVOUS    AND    MENTAL    DISEASES- 

and  spine  are  bent  forward  (very  rarely  the  head  is  bent 
backward)  and  the  face  stares  straight  ahead.  Patients 
are  restless,  uncomfortable  and  unhappy  and  often  com- 
plain of  painful  sensations  of  heat  or  cold.  The  tendon 
reflexes  are  generally  normal,  rarely  exaggerated  and 
there  is  no  nystagnaus.  Paralysis  Agitans. 

Fig.  20. 


PARALYSIS  AGITANS.    {Ftotn  Gowers,  after  St.  Leger.) 


B.  The  disease  generally  begins  in  early  youth  or  adult  life 
but  may  begin  at  any  age.  Weakness  of  the  limbs  or  of 
some  of  the  muscles  supplied  by  the  cranial  nerves  is  usu- 
ally the  first  symptom.  The  tremor  is  characteristic  and 
is  called  intention  tremor  because  it  occurs  when  the  hands 
are  used  and  subsides  during  rest.  It  is  coarse,  jerky 
and  irregular,  the  average  rate  being  about  6  per  second. 
Nystagmus  is  common.  Speech  is  usually  stacatto  or 
scanning  at  first,  in  a  monotonous  voice,  later  becoming 


TREMOR.  141 

slurred  and  indistinct.  The  tendon  reflexes  are  gener- 
ally exaggerated.  A  great  variety  of  other  symptoms, 
such  as  might  be  caused  by  scattered  lesions,  may  occur, 
including  impairment  of  the  visual  fields  for  form  and 
colors,  optic  neuritis,  optic  atrophy,  nervous  deafness, 
and  ataxia.      The  patient  is  often  unduly  complacent. 

Disseminated  Sclerosis. 

C.  The  tremor  is  part  of  a  general  nervous  disturbance, 
generally  in  a  woman,  of  vs^hich  rapid  heart  action,  en- 
largement of  the  thyroid  gland,  protrusion  of  the  eye- 
balls and  general  vaso-motor  dilatation  are  prominent 
symptoms.  The  tremor  may  be  very  fine  and  rapid  or 
it  may  be  so  coarse  and  irregular  as  to  suggest  chorea. 
It  is  usually  elicited  by  voluntary  action. 

Exophthalmic  Goitre. 

D.  Tremor  occurs  only  pn  attempting  to  perforin  a  certain 
habitual  and  highly  coordinated  movement  of  the  hands 
such  as  writing,  engraving  or  playing  on  a  musical  in- 
strument, which  has  been  performed  to  excess.  May 
be  accompanied  by  painful  sensations,  spasm  or  weak- 
ness. Occupation  Neurosis. 

E.  The  tremor  begins  in  old  age,  is  mostly  in  the  hands 
and  head  and  is  fine  and  rapid,  diminishing  during  rest 
and  ceasing  during  sleep.  Rigidity  and  weakness  are 
absent.  Senile  Tremor. 

F.  The  history  and  symptoms  indicate  hysteria  and  no  other 
cause  is  found.  The  tremor  is  very  irregular  both  in 
time  and  amplitude  and  may  shade  into  the  rhythmical 
movements  of  hysteria  described  under  localized  spasms. 

Hysteria. 


142  NERVOUS    AND    MENTAL    DISEASES. 


GENERAL   SPASMS. 

Spasmodic   muscular    contractions    not    limited   to   one 
region  of  the  body. 

I.  Contractions  occur  at  very  short  intervals,  not  in  distinct 
paroxysms,  and  involve  different  groups  of  muscles  in  irregu- 
lar succession. 

A.  The  movements  are  jerky  and  irregular,  at  first  appear- 
ing to  be  such  as  might  be  made  voluntarily  by  a  fidgety 
or  perverse  child,  e.  g.^  grimaces,  thrusting  out  the 
tongue,  jerking  of  the  hands  so  as  to  upset  objects  or 
sudden  relaxation  of  grasp  so  as  to  drop  them,  grotesque 
changes  in  the  posture  of  the  head,  trunk  and  limbs. 
The  movements  usually  affect  the  two  sides  of  the  body 
unequally  and  are  sometimes  limited  to  one  side.  In  a 
severe  case  they  may  become  very  violent.  Speech  is 
often  made  indistinct  or  entirely  arrested.  Often  asso- 
ciated with  rheumatism  and  may  be  complicated  by  en- 
docarditis. Most  cases  occur  between  five  and  fifteen 
years  of  age,  nineteen-twentieths  before  twenty.  Two- 
thirds  of  the  patients  are  girls.  Chorea. 

B.  Movements  bear  a  general  resemblance  to  those  of  chorea 
but  are  less  jerky  and  more  rhythmical.  A  mental  cause 
can  usually  be  found,  especially  imitation  of  other  pa- 
tients.     Other  evidences  of  hysteria  generally  present. 

Hysterical  Chorea. 

C.  Movements  generally  coarser  and  more  pronounced  and 
postures  more  extravagant  than  those  of  chorea.  Begins 
usually  between  thirty  and  forty  years  of  age,  rarely  be- 
fore twenty,  in  members  of  certain  fatnilies.  Ends  in 
dementia.  Hereditary  Chorea. 

D.  Movements  like  those  of  chorea  or  hereditary  chorea. 
Disease  begins  in  middle  or  advanced  life,  is  not  mark- 


GENERAL    SPASMS.  1 43 

eclly  hereditary  and   rarely  ends  in  dementia  or  shortens 
life.  Senile  Chorea. 

E.  Spasmodic  contractions  occur  mostly  in  the  large  muscles 
near  the  trunk,  especially  in  the  quadriceps,  flexors  of 
the  knee,  calf  muscles,  deltoid,  biceps,  triceps,  supina- 
tor, lower  face  and  neck,  the  distal  pait  of  the  limbs 
being  comparatively  unaffected.  The  spasm  usually  ap- 
pears first  in  the  shoulders,  upper  arms  or  face,  and  is 
clonic  or  a  combination  of  clonic  and  tonic,  sometimes 
with  tetanic  exacerbations.  The  clonic  contractions  are 
abrupt,  as  though  due  to  electric  shocks,  and  irregular, 
recurring  from  ten  to  fifty  times  a  minute.  They  may 
affect  single  muscles  not  separately  under  control  of  the 
will  or  successive  parts  of  a  muscle  and  are  usually  not 
sufficient  to  cause  movement  of  the  limbs. 

Paratnyoclonus  Multiplex . 
II.   Contractions  occur    in    a    distinct   paroxysm  or  convulsion 

which  may  or  may  not  recur. 

A.   Consciousness  is  lost  or  obscured  during  the  paroxysm. 

1 .  There  is  evidence  of  organic  disease  of  the  brain  or 
its  membranes,  consisting  of  such  signs  as  globular 
enlargement  of  the  cranium,  inequality  of  pupils, 
absence  of  light  reaction,  paralysis  of  the  face  or  of 
ocular  muscles  or  of  one  side  of  the  larynx,  optic 
neuritis  or  atrophy,  localized  spasm  of  the  Jacksonian 
type  or  a  localized  beginning  of  the  general  spasm, 
typical  ankle  clonus  without  hysterical  contracture, 
etc.  Convulsion  epileptiform.  Persistent  headache 
and  vomiting  common  in  the  intervals. 

Organic  Cerebral  Disease. 
The  differential  diagnosis  is  made  on  the  same 
principles    as    in    hemiplegia.,    whether     this 
symptom  is  actually  present  or  not. 

2.  Signs  of  organic  disease  are  absent. 

a.  Paroxysms  recur,  irrespective  of  any  definite  toxic 
or  reflex  cause,  forming  a  series. 
i.  Aura,  if  it  occur,  short ;   absolute  loss  of  con- 


144  NERVOUS    AND    MENTAL    DISEASES. 

sciousness ;  a  single  cry ;  fall,  regardless  of 
danger  ;  dilatation  of  pupils  ;  tonic  spasm  ; 
cyanosis ;  clonic  spasm ;  frothing  at  mouth, 
often  bloody  from  tongue  having  been  bitten  ; 
involuntary  evacuations  may  occur ;  gradual 
lengthening  of  interval  between  jerking  move- 
ments followed  by  cessation  of  spasin  and  re- 
turn of  consciousness.  During  the  convulsion 
words  are  never  uttered  and  the  movements 
never  express  any  emotion  or  purpose  what- 
ever. Convulsion  lasts  only  a  few  minutes 
and  is  generally  followed  by  deep  sleep. 

Epilepsy  {grand  tnal^. 
ii.  An  e.motional  exciting  cause  frequent.  Pro- 
dromes often  long ;  if  there  is  a  cry  it  may  be 
repeated ;  if  a  fall  it  is  not  utterly  regardless 
of  danger ;  rigidity  ;  contortions,  especially 
arching  the  body  and  placing  the  head  or 
limbs  in  grotesque  positions ;  the  patient  may 
struggle  with  the  attendants  ;  countenance  and 
movements  express  emotion  and  purpose  ;  ex- 
cited exclamations  may  occur ;  tongue  not 
bitten  though  lips  or  hands  may  be ;  no  in- 
voluntary discharges.  Attack  may  last  a  long 
time  and  contortions  be  many  times  repeated ; 
may  often  be  arrested  by  pressure  on  sensitive 
parts  or  by  an  emetic.  Hysteria. 

iii.  An  einotional  exciting  cause  frequent.  Pro- 
dromes often  long ;  actual  onset  usually  sud- 
den. The  limbs  on  both  sides  become  rigid 
and  may  remain  so  vs^ithout  jerking,  the  arms 
in  flexion  or  extension,  the  lower  limbs  in  ex- 
tension v^^ith  the  feet  visually  inverted.  The 
force  of  the  spasm  may  vary  greatly  under  at- 
tempts to  overcome  it.  The  attack  may  last  a 
long  time  but  may  be  arrested  by  an  emetic. 
Other  signs  of  hysteria  present.  Hysteria, 


GENERAL    SPASMS.  I45 

iv.   Onset     sudden     after    an    emotional    exciting 
cause.     Tonic    spasm    affecting    the    muscles 
throughout  the  body  maintains   it   in  a  fixed 
posture.      The  face  is   usually  expressionless 
but  may  express  an  emotion.     At  first  there  is 
great  resistance  to  a  change  of  posture  but  in 
a  few  minutes  the   limbs  yield  to   moderate 
force  and  they  then  remain  for  a  time  in  the 
posture  given  them  ;   but  if  a  limb  is  unsup- 
ported within   fifteen   or    twenty  minutes    its 
weight   begins   to  prevail    and   it   slowly  de- 
scends.    The    duration    of    the    attack  varies 
from  minutes  to  days  but  it  may  be  arrested 
by  an  emetic.      It  is  almost  always  a  symptom 
of  hysteria  and  may  form  only  one  phase  of  an 
hysterical  convulsion ;   occasionally  it  is  asso- 
ciated with  insanity.  Catalepsy. 
Paroxysm  solitary  or,  if  more  than  one,  each  may 
be  attributed  to  a  definite  and  temporary  cause. 
The   convulsion    is    not    in    itself    distinguishable 
from    that  of    epilepsy  and  similar    attacks    may 
afterward  be  repeated  in  series  so  as  to  constitute 
true  epilepsy, 
i.   Patient  an    infant    or    young   child,  generally 
having,  along  with  the  predisposition  to  con- 
vulsions incident  to  its  stage  of  development, 
some   additional    predisposing  cause,  particu- 
larly an  inherited  neurotic  taint  or  rickets. 
§  Digestion  disordered  by  excessive  or  im- 
proper food,  intestinal  parasites  or  gastro- 
enteritis. 

Eclampsia  of   Gastro-enteric  Irrita- 
tion. 
§§   Convulsions  are  associated  with  irritation 
due  to  eruption  of  the  teeth ;   no  other  ex- 
citing cause.        Eclampsia  of  Dentition. 
§§§   Convulsions  mark  the  onset  of  an  acute 


146  NERVOUS    AND    MENTAL    DISEASES. 

infectious  fever,  such  as  scarlatina,  measles 
or  poliomyelitis,  corresponding  to  the  rigor 
of  an  adult  patient. 

Eclampsia  of  Acute  Fever. 

ii.  Patient  generally  an  adult,  but  may  be  of  any  age. 

§   Convulsion  immediately  follows  a  blow^  on 

the  head.  Eclampsia  of  Concussion. 

§§   There  has  been    a  serious  loss  of    blood 

or  an  exhausting  discharge.      Pulse  very 

small    and    weak.      If     the    fontanelle     is 

still  open  it  is  depressed. 

Eclampsia  of  Cerebral  Anemia. 
§§§   There  is  evidence  of  a  toxic  substance  in 
the  circulation. 

!   The  urine  contains  albumen  or  casts 
or  its  specific  gravity  and  total  quan- 
tity   indicate    defective     elimination. 
Signs    of    uremia     common,    e.   g.., 
edema,  pallor,  albuminuric  retinitis. 
Urejnic  Eclampsia.,  including  Pu- 
erperal Eclampsia. 
I  !   History  of  excessive  consumption  of 
alcohol,  perhaps  of  delirium  tremens, 
or    of    other    forms    of    alcoholism. 
Signs  of  alcoholism  common,  such  as 
characteristic     odor    of    the    breath, 
bloated    face    and    bleary   eyes.      No 
other  cause.      Alcoholic  Eclampsia. 
I  !  !   History  of  exposure  to  lead.     Signs  of 
plumbism  present,  e.  g..,  blue  line  on 
the  gums,  dry  colic,  bilateral  wrist- 
drop. Plufnbic  Eclampsia. 
B.   Consciousness  not   essentially  obscured  during  the  par- 
oxysm. 

I .  The  spasm  is  tonic  and  begins  in  the  muscles  of  mas- 
tication, extending  gradually  to  those  of  the  neck, 
spine,   chest  and  abdomen.      Paroxysms   of    general 


GENERAL    SPASMS.  I47 

tonic  spasm  then  occur  and  cause  risus  sardonicus, 
opisthotonos  and  rigidity  of  limbs,  during  which  the 
eyes  are  open  and  the  patient  suffers  severely.  Be- 
tween the  paroxysms  there  is  continuous  tonic  rigid- 
ity, especially  of  the  jaws  and  neck.  History  of  a 
wound  that  may  have  been  infected  through  earth  or 
manure,  or  of  exposure  to  cold,  or,  in  the  new-born, 
an  infection  of  the  umbilicus.  Tetanus. 

3.  Paroxysms  of  bilateral  tonic  spasm  begin  in  the  mus- 
cles of  the  hands,  or  of  the  hands  and  feet,  after  prod- 
romal tingling  and  stiffness ;  spasm  extends  toward 
the  trunk  which  is  also  involved  in  severe  cases. 
Hands  in  obstetric  position,  wrists  and  elbows 
slightly  flexed,  arms  adducted,  toes  flexed,  feet  in 
equino-varus  position,  knees  and  hips  extended  or 
rarely  flexed,  thighs  adducted.  The  jaw  is  not  af- 
fected until  late  in  the  attack  if  at  all.  In  the  inter- 
vals spasm  may  be  excited  by  pressure  on  nerve 
trunks  or  arteries  (Trousseau's  symptom)  .  Galvanic, 
faradic  and  mechanical  irritability  of  the  affected 
muscles  enormously  increased.  Occurs  chiefly  in 
children  often  associated  vvith  rickets  and  sometimes 
with  laryngismus  stridulus  and  eclampsia.  In  adults 
it  may  occur  in  conditions  of  exhaustion  or  after  ex- 
posure to  cold  or  removal  of  the  thyroid  gland. 
Very  rare  in  North  America  and  rare  in  England ; 
more  common  in  continental  Europe.  Tetany. 

3.  History  of  surroundings  may  indicate  probability 
of  poisoning.  Patient  at  first  exhilarated.  Spasm 
comes  on  rapidly,  beginning  in  the  limbs  and  extend- 
ing to  the  trunk  so  as  to  cause  opisthotonos.  Eyes 
open.  Relaxation  in  intervals.  Jaw  affected  later 
in  the  attack  than  other  parts  and  relaxes  earlier. 

Strychnia  Poisoning. 

4.  Onset  from  twelve  days  to  several  months  after  the 
bite  of  a  rabid  animal.  Spasm  begins  in  pharynx, 
causing  dysphagia  and  horror  of  liquids.     A  quick 


148  NERVOUS    AND    MENTAL    DISEASES. 

inspiratory  jerk  and  general  tetanoid  convulsions  are 
soon  added  to  the  pharyngeal  spasm.  Mind  at  first 
clear,  but  delirium  or  frenzy  may  svipervene.  Ex- 
cessively rare  in  North  America.  Hydrophobia. 

III.  Continuous  tonic  spasm  holds  two  or  more  limbs  in  a  fixed 
position,  the  arms  in  rigid  flexion  or  extension,  the  lower 
limbs  generally  in  rigid  extension  wuth  the  feet  inverted  but 
sometimes  in  flexion.  The  onset  is  often  sudden  after  an 
injury  or  an  emotional  disturbance  but  maybe  gradual.  At 
first  the  force  of  the  spasm  varies  greatly  when  attempts  are 
made  to  overcome  it  and  under  variations  in  the  patient's  at- 
tention to  it,  while  under  an  anesthetic  it  relaxes  completely  ; 
but  later  there  may  be  structural  shortening  of  the  muscles 
which  cannot  be  overcome  even  in  profound  anesthesia.  An 
atypical  foot  clonus  can  sometimes  be  obtained  but  unequiv- 
ocal signs  of  organic  disease  of  the  nervous  system  are  absent. 
Other  symptoms,  obviously  hysterical,  are  generally  present. 

Hysterical  Contracture. 

IV.  Permanent  tonic  contraction  of  the  flexors  generally  and 
of  the  muscles  of  the  face  comes  on  very  slowly,  after  forty 
years  of  age,  and  causes  a  characteristic  posture  with  absence 
of  facial  expression.  (Fig.  20.)  The  hands  assume  the 
"  pill-rolling  "  position ;  the  knees,  hips,  v\^rists,  elbo"ws  and 
shoulders  are  somewhat  flexed,  the  head  and  spine  bent 
forward,  or  very  rarely  the  head  bent  backward ;  the  face  is 
blank  and  stares  straight  ahead.  Generally  but  not  always 
preceded  by  a  characteristic  tremor,  which'  begins  in  one 
hand  (or  rarely  in  one  leg)  and  gradually  extends  to  the 
opposite  side.  Patients  are  restless,  uncomfortable  and  un- 
happy and  often  complain  of  painful  sensations  of  heat  or 
cold.  Tendon  reflexes  generally  normal,  rarely  exaggerated. 
There  is  no  nystagmus.  Paralysis  Agitans. 


LOCALIZED    SPASMS.  I49 


LOCALIZED  SPASMS. 

Spasms  limited  to  one  region  of  the  body   in  voluntary 
muscles  that  are  not  paralyzed. 

I.   The  spasm  occurs  only  in  distinct  paroxysms. 

A.  The  attack  begins  in  a  definite  part  of  the  body  com- 
monly with  a  feeling  of  numbness.  Tonic  or  clonic 
spasm  then  occurs  and  may  spread  to  other  parts,  always 
in  an  order  corresponding  to  the  arrangement  of  the 
cortical  motor  centers,  e.  g.^  beginning  in  a  foot  it 
passes  up  the  limb  to  the  trunk,  then  to  the  arm  and 
only  later  to  the  face  ;  beginning  in  the  arin  it  may  next 
affect  either  the  face  or  the  leg.  Consciousness  is  not 
lost  unless  general  convulsion  ensues.  The  convulsed 
part  is  weakened,  or  even  paralyzed,  for  a  time  subse- 
quent to  the  attack,  varying  from  a  few^  minutes  to 
many  hours.  For  the  twenty-four  hours  following  a 
paroxysm  the  total  quantity  of  urinary  solids  is  in- 
creased. When  attacks  occur  many  times  daily  the 
temperature  is  elevated  above  101°  and  there  is  rapid 
mental  deterioration.  Other  signs  of  organic  disease 
usually  present. 

Jacksonian  Epilepsy.  Caused  by  organic  disease 
irritating  the  cortex ;  nattire  to  be  determined  by 
the  accom-paitying  symptoms  and  their  mode  of 
onset. 

B.  The  attack  begins  and  inay  spread  as  in  Jacksonian 
epilepsy  but  the  convulsed  part  is  not  weakened,  there  is 
no  inental  deterioration  and  prolonged  observation  re- 
veals no  other  indication  of  organic  disease.  For  the 
twenty-four  hours  following  an  attack  the  total  quantity 
of  urinary  solids   is  diminished.      The  spasm  may  often 


150  NERVOUS    AND    MENTAL    DISEASES. 

be  excited  by  observation  or  direct  suggestion  and  there 
are  stigmata  or  other  proofs  of  hysteria. 

Hysterical  Simulation  of  Jacksonian  Epilepsy. 

C.  The  spasm  is  in  the  adductors  of  the  larynx. 

1.  The  patient  is  usually  a  child  with  rickets,  most 
commonly  from  six  to  eighteen  months  of  age. 
Respiration  is  suspended  by  sudden  closure  of  the 
glottis ;  the  head  is  thrown  back,  the  face  at  first 
pale  then  livid.  Spasm  of  other  respiratory  muscles 
and  of  hands  and  feet  may  be  associated. 

Laryngismus  Stridulus. 

2.  The  patient  is  a  child  with  catarrhal  laryngitis.  Par- 
tial closure  of  the  glottis  comes  on  during  sleep, 
causing  dyspnea  with  inspiratory  stridor. 

Spasmodic  Croup. 

3.  The  patient  is  a  youth  or  an  adult. 

a.  There  is  absence  of  knee-jerk,  together  with 
Argyll-Robertson  pupil,  ataxic  gait  or  station 
when  eyes  are  closed,  lightning  pains  or  other 
symptom  of  tabes.  Laryngeal  Crisis. 

b.  The  paroxysms  are  traceable  to  an  emotional  dis- 
turbance or  to  suggestion.  Signs  of  organic 
disease  absent ;   stigmata  of  hysteria  present. 

Hysterical  Spas?n  of  Glottis. 
c.   Paroxysms  occur  mostly  at  night  in  neurotic  pa- 
tients,   but   are    not    traceable    to    suggestion    or 
emotion.      Stigmata  of  hysteria  absent. 

Neurotic  Spas7n  of  Glottis. 

D.  The  spasm  is  in  the  constrictor  vaginae  and  levator  ani, 
the  paroxysms  occurring  on  attempted  coitus.  The 
patients  are  newly  married,  neurotic  women. 

Vaginismus. 
11.   The    spasm  occurs  only   on  attempted  use   of    the  affected 
muscles. 

A.  The  spasm  occurs  on  attempting  a  particular  inovement 
which  is  necessar}'  in  the  patient's  occupation  and  has 
been    excessively    repeated,    as    writing     or    playing    a 


LOCALIZED    SPASMS.  I5I 

musical  instrument,  but  does  not  occur  during  rest  or 
when  performing  any  other  action.  Usually  accom- 
panied by  a  feeling  of  fatigue  or  pain. 

Occupation  Neurosis. 

B.  On  attempting  to  stand  spasm  causes  an  alternating 
flexion  and  extension  of  the  lower  limbs.  Rare,  prob- 
ably hysterical.  Saltatoric  Spasm. 

C.  Tonic  spasm  comes  on  when  a  movement  is  attempted 
after  a  period  of  rest,  passing  away  if  the  attempt  is  per- 
sisted in.  Especially  affects  the  legs,  but  may  also  ap- 
pear in  the  hands  or  face.  Hereditary  and  usually 
congenital.      Rare.         Myotonia  (^Thomsen' s  D isease) . 

D.  On  attempting  to  speak  or  perform  some  other  voluntary 
action  of  the  larynx  spasm  of  the  adductors  occurs,  al- 
though all  involuntary  and  automatic  functions  are 
properly  performed.      Rare,  probably  hysterical. 

Phonic  Laryngeal  Spasm. 

III.  The  spasm  causes  persistent  and  rhythmical  movements  of 
alternate  flexion  and  extension  of  the  limbs,  nodding  or  ro- 
tation of  the  head,  protrusion  and  retraction  of  the  tongue, 
etc.  Hysteria. 

IV.  The  spasm  has  no  relation  in  time  to  voluntary  movements, 
which  are  not  seriously  impaired.  The  spasmodic  move- 
ments, such  as  winking,  grinning,  nodding  the  head,  shrug- 
ging the  shovilders,  jerking  a  limb  or  jumping,  have  the  ap- 
pearance of  being  voluntary  although  inappropriate,  but  the}' 
are  repeated  in  spite  of  efforts  to  control  them. 

A.  The  spasm  begins  in  early  life,  often  as  a  voluntary  or 
automatic  movement  due  to  a  definite  exciting  cause,  and 
persists  as  a  habit  after  the  original  cause  has  ceased  to 
act.  Habit  Spasm. 

B.  The  movements  are  more  abrupt  and  rapid  than  those  of 
habit  spasm.  Bodily  and  mental  stigmata  of  degeneracy 
commonly  present.  Often  accompanied  by  an  impulsive 
tendency  to  utter  certain  senseless  expressions,  to  repeat 
the  words  of  others  (echolalia)  or  their  gestures  (echo- 
kinesis)  or  to  utter  obscene  words  (coprolalia)  .      Efforts 


152  NERVOUS    AND    MENTAL    DISEASES. 

to  control  the  impulsive  actions  cause  fatigue  and  distress. 

Convulsive  Tic. 
V.   Spasms  not  included  under  the  previous  headings.     May  he 
tonic  or  clonic  or  both,  v\^ith  or  without  paroxysmal  exacer- 
bations. 

A.  In  muscles  within  the  orbit.    Not  accounted  for  by  errors 
of  refraction.      Positive  signs  of  organic  disease  absent. 

1.  Farthest  point  of  distinct  vision  coincides  with  the 
normal  near  point.  Monocular  polyopia,  micropsia, 
or  macropsia  often  associated  with  the  myopia.  Onset 
usually  sudden.  The  symptoms  are  dispelled  by  the 
use  of  an  appropriate  concave  glass  but  may  not 
yield  promptly  to  atropia.  Often  shown  to  be  hys- 
terical by  the  presence  of  hysterical  amblyopia  or 
other  hysterical  stigmata  or  by  the  curative  effect  of 
suggestion.  Spasm  of  Accommodation. 

2.  There  is  convergent  (or  very  rarely  divergent?) 
squint.  The  double  images  are  at  a  constantly  vary- 
ing distance  from  each  other,  but  do  not  approach  or 
separate  when  the  object  is  moved  from  one  side  to 
the  other  as  in  ocular  palsies.  The  field  of  fixation 
of  either  eye  taken  separately  is  normal  in  recent  cases 
and  in  cases  of  long  standing  is  only  fiattened  on  the 
side  opposite  the  contracted  muscle.  Onset  usually 
sudden,  often  after  an  hysterical  seizure. 

Spasm  of  Extei'nal  Ocular  Muscles. 

B.  Tonic  spasm  of  the  muscles  of  mastication  prevents  the 
jaws  from  being  separated. 

1 .  There  is  evidence  of  organic  intracranial  disease. 
Headache,  vomiting  and  fever  common. 

Organic  Disease.  Nature  to  be  determined 
fro7n  the  accompany i7ig  symptofns  and  their 
mode  of  onset ;  usually  meningitis. 

2.  Signs  of  organic  disease  absent. 

a.  After  an  infected  wound,  especially  one  infected 
by  earth  or  the  refuse  of  stables,  tonic  spasm  be- 
gins in  the  muscles  of  mastication  and  gradually 


LOCALIZED    SPASMS.  l53 

spreads  to  the  muscles  of  the  neck,  spine,  chest 
and  abdomen.  Paroxysms  of  general  tonic  spasm, 
causing  opisthotonos  and  severe  pain,  occur  spon- 
taneously or  on  slight  provocation.  Temperature 
may  be  normal  or  elevated.     The  mind  is  clear. 

Tetanus. 

b.  There  is  a  source  of  reflex  irritation  such  as  caries 
or  faulty  eruption  of  a  tooth,  a  v^^ound  of  the  in- 
ferior maxilla,  inflammation  of  the  temporo-maxil- 
lary  joint  or  suppurative  tonsillitis.  The  spasm 
does  not  spread  and  ceases  vs^hen  the  source  of 
irritation  is  removed.  Reflex  Trismus. 

c.  The  jaws  remain  closed  after  an  hysterical  attack 
or  an  emotional  disturbance  or  in  response  to  sug- 
gestion. No  infection ;  no  reflex  cause.  Other 
signs  of  hysteria  generally  obvious. 

Hysterical  Trismus. 
C.   Spasm  in  the  distribution  of  the  facial  nerve. 

1.  Limited  to  the  orbiculares  palpebrarum,  usually 
clonic  and  bilateral  but  may  be  either  tonic  or  clonic, 
bilateral  or  unilateral.  Tonic  closure  of  the  lids  may 
simulate  paralytic  ptosis  but  is  readily  distinguished 
by  concentric  wrinkles  in  the  skin,  by  the  closure 
being  unaffected  by  posture  and  by  active  resistance 
when  the  physician  attempts  to  open  the  lids.  Pres- 
sure points  of  excitation  or  arrest  common.  Disease 
may  be  reflex,  neurasthenic  or  hysterical. 

Blepharospasm.. 

2.  Especially  affects  the  zygomatici  and  orbicularis 
palpebrarum,  the  orbicularis  oris  being  generally  un- 
affected although  the  platysma,  depressor  anguli  oris 

■  and  levator  menti  are  sometimes  involved.  Mostly 
unilateral  but  may  extend  to  the  other  side.  Some- 
times there  are  brief  paroxysms  of  tonic  and  clonic 
spasm,  soinetimes  single  contractions  occurring  at  ir- 
regular intervals.  Generally  begins  in  the  second  half 
of  life,  very  rarely  before  thirty.  Facial  Spasm. 

13 


154  NERVOUS    AND    MENTAL    DISEASES. 

3.  Tonic  spasm,  to  which  fine  clonic  contractions  are 
added,  retracts  one  angle  of  the  mouth  while  the 
tongue  is  spasmodically  turned  to  the  same  side. 
The  orbicularis  palpebrarum  is  generally  unaffected 
but  the  platysma  may  be  involved.  The  sound  side 
appears  to  be  paralyzed  but  it  is  not  relaxed  and  the 
mouth  opens  more  widely  on  the  side  of  the  spasm. 
Other  signs  of  hysteria  generally  present..     Rare. 

Hysterical  Glosso-labial  Spasm. 

D.  Spasm  limited  to  the  tongue.     It  may  be  tonic,  clonic, 

rhythmical  or  mixed,  paroxysmal  or  continuous. 
Patients  mostly  hysterical  or  epileptic.  Rarely  caused 
by  reflex  irritation.  Glosso-spasm. 

E.  The   spasm  affects  the   rotators  of  the  head,  especially 

the  sterno-mastoid  and  trapezius.  It  is  tonic  or  clonic  or 
tonic  and  clonic  combined.  The  ear  of  the  affected  side 
is  usually  brought  nearer  the  inner  end  of  the  clavicle, 
the  chin  being  elevated  as  well  as  turned  to  the  op- 
posite side,  but  the  head  may  simply  be  rotated. 

1 .  Begins  in  the  second  half  of  life,  only  rarely  before 
thirty.  Not  amenable  to  mental  treatment.  Signs 
of  hysteria  absent  except  very  rarely  when  the  two 
diseases  simply  co-exist.  Spasmodic  Torticollis. 

2.  Occurs  in  youths  or  young  adults  predisposed  to  hys- 
teria. The  influence  of  mental  changes  in  exciting  or 
restraining  the  spasm  is  apparent.  Other  signs  of 
hysteria  present.  Hysterical  Torticollis. 

F.  The  spasm  is  in  the  retractors  of  the  head. 

I.  There  are  signs  of  organic  disease  such  as  inequality 
of  the  pupils,  impaired  light  reaction,  paralysis  of 
eye  muscles  or  of  the  face  or  tongue  or  one  side  of 
the  larynx,  optic  neuritis,  optic  atrophy  or  Jacksonian 
epilepsy,  together  with  headache  and  often  vomiting 
or  with  severe  pain  at  the  back  of  the  neck. 

Organic  Disease  within  the  cranium,  or  upper 
part  of  the  spinal  canal^  most  cof?zmonly  ?}zen- 
ingitis. 


LOCALIZED    SPASMS.  1 55 

2.  Signs  of  organic  disease  absent. 

a.  The  disease  is  chronic  and  begins  usually  in  the 
second  half  of  life,  only  very  rarely  before  thirty. 
The  spasm  is  like  that  of  spasmodic  torticollis. 
Exacerbations  are  made  more  frequent  and  intense 
by  emotion  but  the  disease  is  not  amenable  to 
mental  treatment.  Stigmata  of  hysteria  absent 
except  in  rare  cases  in  which  the  two  diseases 
co-exist. 

Spastnodic  RetrocoUis  (^Bilateral  Torticollis). 

b.  The  spasm  occurs  as  a~"complication  of  a  severe 
fever,  e.  g:^  typhoid.  It  may  easily  be  mistaken 
for  a  symptom  of  meningitis  from  which  it  is  dis- 
tinguished by  the  absepce  of  any  unequivocal  sign 
of  organic  disease  and  by  the  subsequent  course. 

Functiotial  RetrocoUis  of  htfectiotis  Fever. 

c.  Retraction  of  the  head  persists  after  an  hysterical 
convulsion  or  occurs  in  response  to  suggestion. 

Hysterical  RetrocoUis. 
G.  Tonic  spasm  causes  persistent  rigidity  of  some  part  of 
the  spine  and  is  liable  to  exacerbations,  perhaps  with 
the  addition  of  clonic  spasm.  Pain  is  felt  in  the  affected 
part  of  the  spine  and  there  are  also  radiating  pains  in 
the  course  of  the  nerves  issuing  from  this  part,  often 
causing  girdle  sensation.  At  first  there  is  hyperesthesia 
in  the  distribution  of  these  nerves  but  later  there  may 
be  anesthesia  and  atrophic  paralysis.  Paraplegia  and 
sensory  loss  up  to  the  level  of  the  affected  part,  together 
with  disturbance  of  the  bladder  and  rectum,  may  even- 
tually appear  showing  that  the  substance  of  the  cord  has 
become  diseased. 

I.   Deformity  or  swelling  with  deep-seated  tenderness 
indicates  disease  of  the  vertebrae. 

a.  The  patient  is  usually  a  child,  sometimes  a  yovmg 
adult,  rarely  an  elderly  person.  The  tubercular 
diathesis  is  almost  always  manifest  but  very  rarely 
syphilis  may  be  the  cause.     The  pain  is  generally 


156  NERVOUS    AND    MENTAL    DISEASES, 

of  moderate  severity,  increased  by  motion  or  jars 
and  diminished  by  rest  of  the  spine.  Prominence 
or  lateral  displacement  of  one  or  more  spinous 
processes  is  the  characteristic  deformity. 

Spinal  Caries. 
b.   The  patient   is  in  the  second  half   of   life,   often 
with  a  history  of  tumor  elsewhere  or  of  predis- 
position to   new  growths   or  to   aneurism.     The 
pain  is  very  intense  and  is  very  greatly  aggravated 
by  inotion. 
§   The  radiating  pain  is  on  the  left  side  of  the 
chest.      Characteristic    thrill    and    murmur    at 
the  seat  of  pain  and  deformity. 

Spinal  Aneurism. 
§§   Radiating  pains  on  both  sides.     No  thrill  or 
murmur.  Spinal  Tumor. 

2.   Nothing  to  indicate  disease  of  the  vertebras. 

a.  Onset  sudden.     No  fever  at  first. 

Spinal  Meningeal  Hemorrhage. 

b.  Onset  acute,  marked  by  chill  and  fever. 

Acute  Spinal  Meningitis. 

c.  Onset  chronic. 

i.   History  of  alcoholism,  syphilis  or  exposure  to 
cold.  Chronic  Spinal  Meningitis. 

ii.   Evidence  of  predisposition  to  new^  growths.     No 
other  cause  of  meningitis. 

Intraspinal  Tumor. 
H.   The  spasm  is  in  the  muscles  of  a  single  joint,  most  fre- 
quently the  hip,  knee,  shoulder  or  ankle. 
I.   The  joint  is  persistently  rigid,  the  spasm  not  being 
relaxed  when  attention  is  withdrawn  nor  even  during 
sleep,  nor  is  it  overcome  by  moderate,  persistent  force. 
Any  attempt  to  move  the  joint  causes  pain  ^\"hich  is 
not  superficial  and  not  markedly  affected  by  attention. 
Complaints  of  pain  are  often  involuntary  and  accom- 
panied by  the  facial  expression   of  suffering ;   night 
startings  and  cries  are  common.     The  muscles,  espe- 


LOCALIZED    SPASMS.  1 57 

cially  the  extensors,  are  wasted  more  than  disuse  would 
account  for,  and  their  electrical  reactions  may  be  di- 
minished. The  local  temperature  is  almost  always 
persistently  elevated  one-half  a  degree  to  three  de- 
grees;  very  rarely  it  is  normal  or  subnormal.  The 
posture  is  never  one  of  complete  flexion  or  complete 
extension  but  is  that  of  greatest  ease.  The  symptoms 
do  not  undergo  marked  change  in  a  short  time. 
Under  profound  anesthesia  the  spasm  relaxes  and 
then  additional  signs  of  joint  disease  are  apparent. 

Reflex  Spasm  of  Joint  Disease. 
2.  The  spasm  relaxes  more  or  less  during  sleep  and  may 
often  be  entirely  overcome  by  persistent  moderate 
force  if  the  patient's  attention  is  withdrawn.  The 
pain  complained  of  is  far  greater  than  the  other  signs 
of  disease  would  lead  one  to  expect,  but  is  often  super- 
ficial and  is  markedly  affected  by  attention.  Night 
startings,  involuntary  cries  and  facial  signs  of  suffer- 
ing are  absent.  The  muscles  are  not  wasted  more 
than  disuse  would  account  for  and  their  electrical  irri- 
tability is  normal.  The  local  temperature  is  gener- 
ally normal  or  subnormal  ;  rarely  it  is  temporarily 
elevated,  never  persistently  so.  The  posture  often 
differs  widely  from  that  of  greatest  ease  and  in  many 
cases  automatic  actions  which  would  cause  great  pain 
in  real  joint  disease  are  performed  without  complaint. 
The  symptoms  often  change  greatly  in  a  short  time. 
Examination  under  anesthesia  reveals  no  signs  of 
joint  disease. 

Hysterical  Simulatioit  of  Joiiit  Disease. 
I.  Continuous  tonic  spasm  of  one  arm  or  one  leg  or  of  arm  and 
leg  on  one  side,  leaving  the  face  free,  fixes  the  arm  in  rigid 
flexion  or  extension,  the  lower  limb  in  rigid  extension  with 
the  foot  usually  inverted.  The  onset  is  often  sudden  after 
an  injury  or  an  emotional  cause.  The  force  of  the  spasm 
varies  greatly  when  attempts  are  made  to  overcome  it  and 
under  variations  in  the  patient's  attention  to  it.     Anesthesia 


158  NERVOUS    AND    MENTAL    DISEASES. 

of  the  hysterical  type  often  exists  over  the  affected  muscles, 
sometimes  over  the  whole  limb  or  the  affected  half  of  the 
body.  An  atypical  foot  clonus  can  sometimes  be  obtained, 
but  unequivocal  signs  of  organic  disease  are  absent.  Other 
symptoms  of  hysteria  are  generally  present. 

Hysterical  Contracture. 


OPTIC    NEURITIS.  I59 


OPTIC  NEURITIS. 

The  optic  papilla  is  swollen  and  its  margin  is  obscured 
by  inflammatory  exudate.  Some  vessels  may  be  hidden 
here  and  there  by  the  exudate  and  the  veins  may  be  tortu- 
ous and  overdistended.  Venous  hemorrhages  may  occur. 
Where  the  veins  pass  over  the  inclined  margin  of  the  disk 
they  appear  darker  because,  not  being  at  right  angles  to 
the  line  of  vision,  their  central  light  reflex  is  lost.  The 
neuritis  is  said  to  be  slight  when  the  papilla  is  but  slightly 
swollen  and  its  margin  not  altogether  obscured ;  it  is  in- 
tense when  the  papilla  is  much  swollen  and  appears  to 
extend  far  beyond  its  normal  margin,  which  is  entirely 
obscured.  In  such  cases  the  veins  are  usually  distended 
and  hemorrhages  are  common,  giving  rise  to  the  term 
choked  disk.  This  intense  neuritis  without  retinitis  is 
highly  characteristic  of  intracranial  tumor.  When  both 
the  papilla  and  the  retina  are  inflamed  the  condition  is 
called  neuro-retinitis. 

I.   The  neuritis  is  almost  always  unilateral  and  is  caused  by  in- 
flammation, hemorrhage  or  new  growth  within  the  orbit. 
II.   Neuritis  almost  always  bilateral,  not  caused  by  disease  within 
the  orbits. 

A.  Confirmatory  signs  of  the  existence  of  organic  intra- 
cranial disease  (such  as  paralysis  of  ocular  muscles,  face, 
tongue  or  one  side  of  larynx,  paralysis  of  limbs  that  is 
not  spinal,  peripheral  or  functional,  Jacksonian  epilepsy, 
typical  ankle  clonus,  coincident  mental  impairment,  etc.) 
are  absent.  The  optic  neuritis  is  almost  always  slight 
and  may  be  accounted  for  by  a  systemic  condition  or 
by  the  presence  of  disease  outside  the  cranium. 


l6o  NERVOUS    AND    MENTAL    DISEASES. 

1 .  The  blood  is  very  greatly  impoverished  as  in  severe 
simple  anemia,  pernicious  anemia  or  leucocythemia. 
Hemorrhagic  retinitis  is  generally  present. 

2.  There  is  a  systemic  infection  as  in  variola,  scarlatina, 
measles,  severe  malaria,  influenza,  diphtheria,  typhus, 
typhoid  or  puerperal  fever  or  syphilis.  Optic  neu- 
ritis without  other  signs  of  organic  disease  is  rare  in 
all  of  these  diseases  and  when  it  occurs  is  usually 
part  of  a  neuro-retinitis. 

3.  There   is   a  condition  of  toxemia ,  as  in  uremia,  alco- 

FiG.  21. 


liij,  ,   Mlh 

Healthy  Optic  Disk.     (From  Ormerod,  after  Nettleship  atid  Jdger) 


holism,   plumbism,    chorea,    gout,    hydrargyrism    or 
tobacco  poisoning.      Optic  neuritis  is  very  rare  except 
in    uremia,    where     there    is    usually    in    addition    a 
characteristic    retinitis,   and    in    chorea,   where    very 
slight  neuritis  is  said  to  occur  in  from  eight  to  ten 
per  cent,  of  all  the  cases. 
4.   There  is  disease  outside  the  cranium  with  which  the 
optic   neuritis  is   connected  in  a  way  not  now  under- 
stood, e.  g:,  inflammation  or  injury  of  the  upper  part 
of  the  spinal  cord,  suppurative  otitis  media  or  acute 
suppression  of  menstruation. 
B.  Confirmatory  signs  of  organic  cranial  or  intracranial  lesion 
are    present    or    appear    in   the  course  of   the    disease. 


OPTIC    NEURITIS. 


l6l 


Headache  and  vomiting  are  common.  There  is  no 
disease  ontside  the  cranium  sufficient  to  account  for  the 
optic  neuritis  and  the  accompanying  S3'mptoms.  The 
optic  neuritis  is  often  intense  in  tumor,  very  rarely  so  in 
other  conditions. 

I.  The  cranium  is  injured  or  diseased  in  such  a  v\^ay  as 
to  affect  the  optic  nerve  directly  or  to  cause  menin- 
gitis, which  in  turn  causes  the  neuritis,  as  in  fi^actures 


Fig. 


Intense  Optic  Neuritis.     {From  Ormevod,  after  Netileship  and  Jackson.) 


at  the  base,  caries   of  the  sphenoid  bone  or  chronic 
thickening  of  the  cranial  bones. 
2.   There  is   no    external   evidence  of   cranial   injury   or 
disease  ;   the  lesion  is  intracranial. 

a.  The  disease  is  congenital  or  develops  gradually  in 
infanc}'.  There  is  globular  enlargement  of  the 
cranium.  Hydrocephalus. 

b.  The  onset  of  cerebral  svmptoms  is  sudden  or  very 
rapid,  in  a  few  seconds  to  a  few  hours.  Optic 
neuritis  slight. 

i.   Onset   coincident   with  a    blow  on   the    head 


14 


NERVOUS    AND    MENTAL    DISEASES. 

which  causes  loss  or  disturbance  of  conscious- 
ness.    No  evidence  of  a  vascular  lesion. 

Cerebral  Concussion. 
ii.  Onset  coincident  with,  or  follows  a  blow  on 
the  head,  or  occurs  spontaneously  during  a 
weakened  condition  of  the  cerebral  arteries. 
Hemorrhage  is  indicated  by  headache  on  the 
side  of  the  lesion  (usually  the  side  of  the  more 
intense  neuritis)  or  by  cranial  nerve  palsies  on 
this  side  or  by  paralysis  of  face  or  limbs, 
often  preceded  by  spasm,  on  the  opposite 
side ;  also  by  sopor,  coma  and  slowness  of 
pulse.  Menhigeal  Hemorrhage . 

iii.  Onset  sudden,  marked  by  loss  or  disturbance 
of  consciousness  and  hemiplegia.  There  is 
no  traumatic  cause  but  an  infectious  endo- 
carditis  or    a   pulmonary   abscess    is    present. 

Cerebral  Em.bolis77t. 

c.  Onset  acute  or  subacute,  in  a  few  hours  to  a  few 
weeks,  with  irregular  fever.  A  source  of  intra- 
cranial irritation  or  infection  is  present,  e.  g.^  sup- 
purative otitis  media,  tuberculosis,  pneumonia, 
epidemic  influence,  wound  of  the  head  or  sun- 
stroke. General  hyperesthesia  in  the  earlier  stage 
is  followed  by  delirium  which  merges  into  stupor 
and  coma.  Spasm  of  the  neck,  general  and 
local  convulsions  and  cranial  nerve  palsies  are 
common. 

Meningitis^  or  in  rare  cases  abscess  or  diffuse 
cerebritis ;  differential  diagnosis  not  always 
possible. 

d.  Onset  chronic,  in  six  weeks  or  longer. 

i.  There  is  a  source  of  purulent  infection,  e.g.., 
an  infected  wound  of  the  scalp  or  cranium 
(especially  compound  fracture),  otitis  inedia, 
empyema  or  abscess  in  any  part  of  the  body. 
Rigors  followed  by  fever  and  sweating  com- 


OPTIC    NEURITIS.  163 

mon.  Temperature  irregular,  usually  ele- 
vated bvit  sometimes  depressed.  Duration 
may  be  short  or  it  may  be  long  with  a  period 
of  latency.  InU'acranlal  Abscess. 

No  source  of  infection  but  a  personal  or  family 
predisposition  to  new  growths  may  be  ap- 
parent. Temperature  normal  or  nearly  so. 
Headache  generally  intense,  often  accompa- 
nied by  giddiness  and  vomiting.  Progressive 
mental  failure  occurs  toward  the  end.  Optic 
neuritis  the  most  characteristic  symptom ;  it 
is  present  in  four-fifths  of  all  the  cases  and  is 
usuall}'  intense.  Course  long  and  mostly 
progressive. 

Intracra7iial  Tumof'.,  including  aneurism 
and  hydatid  cyst. 
Patient  alcoholic  or  syphilitic.  Fever  absent 
or  slight.  Optic  neuritis  not  intense.  Or- 
ganic disease  indicated  by  spasm  or  paralysis 
in  the  distribution  of  cranial  nerves,  rarely  in 
the  limbs.  Chronic  Meningitis. 

Optic  neuritis  occurs  very  rarely  in  paretic 
dementia,  disseminated  sclerosis  and  chronic 
cerebritis,  but  is  not  likely  to  be  an  important 
factor  in  the  diagnosis  of  any  of  these  con- 
ditions. Paretic  dementia  is  usually  easily 
recognized  by  its  peculiar  mental  symptoms 
together  with  some  sign  of  organic  disease ; 
disseminated  sclerosis  by  intention  tremor, 
nystagmus,  scanning  speech,  inconstant  and 
irregu-lar  paralyses,  etc.  Chronic  cerebritis 
can  not  now  be  distinguished  during  life  from 
tumor  or  chronic  meninp-itis. 


164  NERVOUS    AND    MENTAL    DISEASES. 


OPTIC   ATROPHY. 

The  optic  disc  is  sharply  defined  and  abnormally  white, 
having  lost  its  normal  rosy  tint,- owing  to  the  disappearance 
of  the  capillary  vessels.  The  retinal  arteries  and  veins  are 
generally  smaller  than  normal. 

I.  The  atrophy  is  secondary  to  optic  neuritis,  which  may  be 
shown  either  by  an  earlier  ophthalmoscopic  observation  or 
by  the  presence  of  exudate  in  the  nerve  head,  concealing  the 
lamina  cribrosa  and  giving  a  "  filled  in"  appearance  to  the 
disc  and  sometimes  extending  outward  along  the  retinal 
vessels.  The  appearance  of  the  disc  alone  is  not  always 
sufficient  to  distinguish  post-neuritic  atrophy  from  simple 
atrophy. 

Diagnosis  to  be  made  as  in  Optic  Netwitis^  q.  v. 

II.   The  atrophy  is  non-neuritic,  or  simple,  which  maybe  shown 

by  the  absence  of  an  earlier  observation  of  neuritis  and  the 

absence  of  exudate  in  the  nerve  head  and  along  the  retinal 

vessels.     The  lamina  cribrosa  is  more  exposed  than  normal. 

A.  The  atrophy  is  almost  always  unilateral  and  is  caused 
by  hemorrhage,  inflammation  or  new  growth  within 
the  orbit. 

B.  The  atrophy  is  almost  always  bilateral  and  is  not  caused 
by  disease  within  the  orbits. 

I .  Confirmatory  signs  of  the  existence  of  organic  dis- 
ease of  the  central  nervous  systeni  (such  as  paralysis 
of  the  ocular  muscles,  face,  tongue  or  one  side  of  the 
larynx,  paralysis  of  the  limbs  that  cannot  be  ex- 
plained as  functional,  Jacksonian  epilepsy,  typical 
ankle  clonus,  absence  of  knee-jerk,  Argyll-Robertson 
pupil,  coincident  mental  impairment,  etc.)  are  absent. 
Although  only  rarely  found  apart  from  other  evidence 


OPTIC    ATROPHY. 


165 


of  organic  nervous  disease,  the  atrophy  may  be  ex- 
plained as  the  effect  of  a  systemic  condition,  an  in- 
herited influence,  or  a  severe  neuralgia,  or  migraine, 
or  as  the  first  symptom  of  an  organic  disease. 

a.  The  blood  is  very  greatly  impoverished  as  in  se- 
vere simple  anemia,  pernicious  anemia  or  leuco- 
cythemia. 

b.  There  is  a  systemic  infection,  as  in  variola,  scar- 
latina, severe  malaria,  diphtheria,  typhus  fever, 
typhoid  fever  or  syphilis. 


Fig.  2^^. 

"^^^^ 

i-<-<; 

M^::-|^''::l 

1 

-  •--^^^^'-i^iV 

^■.^- 

^*^ 

k^ 

yj  x)''A 

^ 

'■  V  ((■I'll 

Atrophy  of  Disc  after  Papillitis. 
{From  Ormerod,  after  Nettleship.) 

Fig.  24. 


Atrophy  of  Disc  from  Spinal  Disease. 
Lamina  Cribrosa  Concealed,  Vessels  Normal. 
{From  Ormerod,  after  Nettleship  and  Weaker.) 


c.  There  is  a  condition  of  severe  toxemia,  as  in 
uremia,  gout,  diabetes,  alcoholism,  plumbism, 
hydrargyrism,  chorea  or  poisoning  by  tobacco  or 
carbon  disulphide. 


l66  NERVOUS    AND    MENTAL    DISEASES. 

d.  The  atrophy  follows    long-continued  and    severe 
'  ophthalmic  neuralgia  or  migraine.     Very  rare. 

e.  The  atrophy  occurs  in  youths  or  young  adults  of 
certain  families  with  no  apparent  cause  except 
hereditary  influence.     Very  rare. 

f.  The  atrophy  occurs  without  any  associated  symp- 
toms or  evidence  that  it  is  hereditary. 

P^'obably  Tabes  or  Paretic  Dementia^  of -which 
other  symptoms  will  appear  later. 
2.   Confirmatory  signs  of  the  existence  of  organic  dis- 
ease of  the  central  nervous  system  are  present. 

a.  The  cranium  is  injvired  or  diseased  in  such  a  way 
as  to  interrupt  fibers  of  the  optic  nerves  or  optic 
tracts,  as  in  fracture  at  the  base  or  chronic  thicken- 
ing of  the  bones. 

b.  There  is  no  evidence  that  the  cranium  is  primarily 
affected ;   the  lesion  is  intracranial  or  spinal. 

i.   The  disease   is   congenital  or  develops  grad- 
ually in  infancy.      There  is  globular  enlarge- 
ment of  the  cranium.  Hydrocephalus. 
ii.   The   onset   of   the   disease  which   causes    the 
atrophy  is  sudden  and — 
§   Coincident  with  a  blow  on  the  head  and 
loss  of  consciousness. 

Cerebral  Concussioii. 
§§  Without   external  violence.-      Hemiplegia 
occurs  as  consciousness  is  lost. 
!  Age  usually  less  than  40.     There  is  a 
septic  endocarditis  or  a  pulmonary  ab- 
scess. Cerebral  Etnbolism. 
!!   Age  usually  more  than  40.    The  arteries 
are  degenerated.      There   may  be  evi- 
dence of  increased  blood  pressure  at  the 
time  of  onset. 

Cerebral  Hemorrhage. 
iii.   The   onset   of   the   disease  which   causes   the 
atrophy  is  gradual  and  slow. 


OPTIC    ATROPHY.  167 

§  The  knee-jerks  are  lost  and  the  Argyll- 
Robertson  pupil  is  present.  A  history 
of  lightning  pains  in  the  legs  is  com- 
mon, also  of  transient  diplopia,  ptosis, 
loss  of  sexual  power  or  difficulty  in 
voiding  or  retaining  the  urine.  Ataxia 
of  station  and  gait  is  usually  present  in 
some  degree  but  is  especially  apt  to  be 
slight  in  cases  where  optic  atrophy 
occurs  early.  This  disease  causes 
simple  optic  atrophy  more  frequently 
than  all  the  other  causes  combined. 

Tabes. 
§§  Failure  of  judgment  and  memory,  often 
combined  with  monstrous  and  un- 
systematized delusions  of  grandeur, 
accompanies  the  signs  of  organic  dis- 
ease, among  which  inequality  of  pupils 
and  stumbling  speech  are  common. 

Paretic  Dementia. 
§§§   Intention  tremor  with  nystagmus,  tran- 
sient    spastic     paralysis    or    scanning 
speech  is  present.     Knee-jerks  usually 
exaggerated.      Optic  atrophy  slight. 

Disseminated  Sclerosis. 
§§§§  The  course  of  the  disease  is  marked  by 
severe  headache,  often  accompanied  by 
vomiting  and  vertigo.  Pulse  often  slow. 
The  state  of  the  visual  fields  and  other 
localizing  symptoms  indicate  a  pro- 
gressive lesion  affecting  one  optic  nerve 
or  the  chiasm.  Intracranial  Tumor. 
§§§§§  Optic  atrophy  may  occur  in  lateral 
sclerosis  and  in  bulbar  paralysis  but  so 
rarely  that  the  mere  mention  of  the 
possibility  is  sufficient. 


NERVOUS    AND    MENTAL    DISEASES. 


TROPHIC    AND   VASO-MOTOR   SYMPTOMS. 

I.   There  is  atrophy  of  one  or  more  muscles. 

A.  The  atrophied  muscles  are  those  which  move  a  diseased 
joint  and  the  atrophy  is  secondary  to  more  or  less  fixa- 
tion of  the  joint.  Faradic  irritability  usually  retained, 
but  may  be  diminished. 

Arthritic  Muscular  Atrophy. 

B.  The  muscles  are  wasted  independently  of  joint  disease  or 
disuse  and  are  paralyzed.  Faradic  irritability  almost 
always  lost  or  diminished  and  reaction  of  degeneration  is 
common  when  the  wasting  is  rapid. 

Diagnosis  as  in  Paralysis. 
II.   There  is  hypertrophy  or  atrophy  of  bones. 

A.  There  is  a  gradual  and  symmetrical  enlargement  of  the 
hands  and  feet,  including  the  bones  and  soft  parts.  The 
fingers  are  sausage-shaped  and  the  nails  broad  and  flat. 
The  lower  and  upper  jaw,  orbital  ridges,  nose,  tongue 
and  ears  also  become  enlarged,  causing  a  characteristic 
deformity  of  the  face.  Headache  and  ocular  symptoms 
very  common.  Patient  an  adult,  more  frequently  a 
woman.  Autopsy  and,  in  many  cases,  the  symptoms 
during  life  reveal  intracranial  disease  affecting  the  pitui- 
tary body.  Acromegaly. 

B.  The  bones  of  the  hands  and  feet,  especially  the  terminal 
phalanges,  are  enlarged.  The  fingers  and  toes  are  ex- 
cessively clubbed  and  the  nails  much  curved.  The  ends 
of  the  long  bones  are  also  enlarged  and  the  joints  are  in- 
volved but  the  face  and  skull  are  not  affected.  The  pa- 
tient is  an  adult,  more  frequently  a  man,  with  chronic 
pulmonary  disease.  There  is  nothing  to  indicate  intra- 
cranial disease.      Very  rare. 

Hypertrophic  Pulmoitary  Osteo-arthropathy, 


TROPHIC    AND    VASO-MOTOR    SYMPTOMS.  1 69 

C.  The  bones  of  the  cranium  and  face  are  enlarged.  Vari- 
ous cranial  nerve  symptoms  may  occur,  owing  to  pressure 
or  obstruction  of  foramina.  Disease  usually  begins  in 
childhood  or  at  puberty.  Inferior  maxilla  and  extremi- 
ties not  affected.  Called  Leontiasis  ossea  by  Virchow. 
Megalocephalie  by  Starr.     Very  rare. 

Hyperostosis  Cranii  (^Putnatn). 

D.  There  is  progressive  atrophy  of  the  bones  and  soft  parts 
of  one  side  of  the  face.  Hair  and  teeth  fall  out.  Very 
rare.  Facial  Heini- atrophy . 

III.  There  is  trophic  disease  of  one  or  more  joints.  The  carti- 
lages are  eroded  and  the  ends  of  the  bones  wasted  or  perhaps 
enlarged  by  irregular  bony  deposits.  There  may  be  edema 
around  the  joint  and  copious  effusion  into  it. 

A.  The  knee-jerks  are  absent.  A  history  of  lightning 
pains  in  the  legs  is  common,  also  of  loss  of  virility  and 
slight  difficulty  in  voiding  or  retaining  the  urine.  The 
patient  sways  on  standing  with  eyes  closed  and  in  the 
later  stages  the  gait  is  ataxic.  Argyll-Robertson  pupil 
in  most  cases.  Tabes. 

B.  There  is  loss  of  sensibility  to  pain  and  temperature  in 
areas  where  touch  is  retained.  There  is  usually  par- 
alysis of  somewhat  variable  and  irregular  distribution, 
most  commonly  atrophic  in  the  arms  and  spastic  in  the 
legs.  Syringomyelia. 

C.  The  joint  disease  is  on  the  same  side  as  hemiplegia  and 
secondary  to  it.     No  other  cause. 

Hemiplegic  Arthropathy. 

D.  The  joint  disease  is  secondary  to  paraplegia  v\^hich  is 
accompanied  by  loss  of  control  of  the  bladder  and 
rectum  and  more  or  less  sensory  loss,  indicating  some 
form  of  myelitis.  Myelitic  Arthropathy. 

IV.  The  disturbance  is  in  the  skin  and  subcutaneous  tissue  vs^ith- 
out  marked  involvement  of  the  bones. 

A.  Sloughing  occurs  in  a  paralyzed  part,  especially  where 
the  skin  is  subjected  to  pressure  or  the  irritation  of  heat 
or  a  blister.  Diagnosis  as  iii  Paralysis. 


lyo  NERVOUS    AND    MENTAL    DISEASES. 

B.  A  painless,  indolent  ulcer  appears  in  the  sole  of  the  foot 
or,  very  rarely,  in  the  hand.  It  resists  treatment  and 
tends  to  penetrate  deeply.  Absence  of  knee-jerk  and 
various  other  symptoms  indicate  the  existence  of  tabes. 

Perforating  Ulcer  in  Tabes. 

C.  The  disturbance  is  in  the  peripheral  distribution  of  cer- 
tain nerves  (most  frequently  the  musculo-spiral  and 
external  popliteal)  which  are  generally  tender.  The 
skin  is  at  first  reddened  and  gradually  becomes  smooth 
and  glossy.  When  the  hand  is  affected  the  fingers  be- 
come pointed.  Adhesions  may  form  in  the  joints. 
There  is  numb,  stinging  pain,  usually  quite  severe  and 
more  or  less  sensory  loss  in  the  affected  area.  The  cor- 
responding muscles  are  paralyzed  and  tender  and  waste 
and  lose  their  faradic  irritability.  A  local  or  general 
cavise  of  neuritis  is  present.  Neuritis. 

D.  Vesicles  appear  in  the  area  supplied  by  one  or  more 
spinal  segments  or  in  one  or  more  of  the  cranial  sensory 
areas  described  by  Head.  (Figs.  25,  26,  27,  28  and 
29.)  Numb,  stinging,  generally  very  severe  pain  is  felt 
in  the  same  area.      The  vesicles  ulcerate  and  leave  scars. 

Herpes  Zoster.     A  symptom  of  irritation  of  the  pos- 
terior root  ganglia  or  of  the  Gasserian  ganglion. 

E.  The  skin  and  subcutaneous  tissue  throughout  the  body 
gradually  become  thickened.  The  swelling  is  firm  and 
does  not  pit  on  pressure.  The  face  has  a  coarse,  puffy, 
round  appearance  and  the  hair  is  thin.  The  mind  be- 
comes dull,  simulating  dementia.  The  thyroid  gland  is 
alw^ays  diseased  and  its  function  diminished  but  it  may 
be  either  atrophied  or  enlarged.  Administration  of  thy- 
roids causes  marked  improvement.  The  disease  may 
be  congenital  in  goitrous  dwarfs  especially  in  Switzer- 
land and  other  moimtainous  countries  (thyroid  cretinism) , 
or  it  may  be  acquired  in  adult  life,  six  women  being 
affected  to  one  man,  or  it  may  be  caused  by  operative 
removal  of  the  thyroid  (cachexia  strumiprava) . 

Myxedema, 


TROPHIC    AND    VASO-MOTOR    SYMPTOMS.  171 

F.  There  is  arrest  of  circulation,  usually  in  the  extremities 
(fingers,  toes,  nose,  ears)  and  symmetrical,  but  it  is  some- 
times unsymmetrical  and  may  affect  the  trunk  and  proxi- 
mal parts  of  limbs.  The  disease  begins  with  local 
pallor  and  a  feeling  of  icy  coldness  (local  syncope), 
which,  after  a  variable  time,  is  followed  by  cyanosis 
(local  asphyxia)  and  later  by  gangrene.  In  the  cyanotic 
and  gangrenous  stages  there  may  be  intense  pain. 

Raymaud' s  Disease. 

G.  The  skin,  either  generally  or  locally,  is  first  thickened 
and  hardened,  later  wasted,  appearing  to  be  stretched  over 
and  bound  down  to  the  underlj'ing  parts.  The  hands 
(sclerodactylie)  and  face  are  most  often  affected. 
Motion  may  be  impeded  by  the  hardened  skin.  Local- 
ized patches  probably  correspond  to  the  distribution  of 
spinal  segments  or  nerve  trunks.  The  disease  generally 
begins  in  youth  or  early  adult  life,  three-fourths  of  the 
patients  being  females.  It  may  be  associated  with 
Raynaud's  disease.  Scleroderma. 

H.  There  are  destructive  trophic  changes  in  the  fingers,  es- 
pecially in  the  terminal  phalanges,  like  those  of  a  felon, 
but  painless.  Neuralgic  pains  may  occur  independent 
of  the  trophic  changes.  Sensibility  to  temperature  and 
pain  is  lost  in  areas  where  touch  is  retained.  Various 
other  cord  symptoms,  especially  paralysis  of  the  type 
found  in  amyotrophic  lateral  sclerosis,  may  confirm  the 
diagnosis  of  syringomyelia. 

Morvan^s  Disease.,  a  special  form  of  syringomyelia. 
I.  There  are  symmetrical  fatty  tumors  in  the  subcutaneous 
tissue  which  are  tender  and  painful.  Patients  usually 
alcoholic  or  syphilitic.  Adiposis  Dolorosa  {Dercuni). 
J.  There  are  subcutaneous  and  perhaps  submucous  swell- 
ings affecting  principally  the  face,  lips,  tongue,  pharynx, 
genitals  and  limbs.  The  swelling  is  well  defined,  tense, 
not  tender,  does  not  pit  on  pressure  and  may  be  either 
^vhite  or  pink.  It  comes  on  rapidly,  in  a  few^  minutes 
to   a   few  hours   and  after   lasting   hours   or   days   may 


172  NERVOUS    AND    MENTAL    DISEASES. 

rapidly  disappear,  recurring  at  regular  or  irregular  in- 
tervals. Gastro-intestinal  pains  are  common.  Neuro- 
pathic heredity  is  very  marked  in  many  of  the  cases. 

Angioneurotic  Edema. 
K.  There  is  pain  in  one  foot,  very  rarely  in  both  feet  or  in 
a  hand,  associated  with  redness  and  often  with  swelling 
and  increased  local  temperature,  sometimes  v\^ith  hy- 
perhidrosis  and  local  hemorrhages.  All  the  symptoms 
tend  to  subside  when  the  patient  reclines  and  rests  the 
foot  in  an  elevated  position ;  they  are  also  relieved  by 
cold  and  aggravated  by  warmth.  Standing  and  letting 
the  foot  hang  brings  on  a  paroxysm  of  pain  accoin- 
panied  by  a  rose-red  flush  and  arterial  throbbing ;  there 
is  no  cyanosis  or  gangrene.  Occurs  almost  exclusively 
in  men,  either  alone  or  in  association  with  various  other 
nervous  affections.  Erythromelalgia. 

L.  There  is  an  edematous  swelling  of  a  limb  which  is 
hysterically  paralyzed,  or  contractured,  or  exhibits  the 
hysterical  simulation  of  joint  disease.  The  swelling 
does  not  pit  on  pressure  and  is  greatest  in  the  morning. 
The  part  may  be  unchanged  in  color  and  temperature,  or 
may  be  red  and  warm,  but  is  mostly  cyanotic  and  cold. 

Hysterical  Edema. 
V.  There  is  a  general  vaso-motor  dilatation  with  rapid  heart  ac- 
tion and,  in  most  cases,  goitre  and  protrusion  of  the  eye- 
balls. The  carotids  pulsate  strongly,  there  is  a  character- 
istic thrill  and  murmur  in  the  enlarged  thyroid  and  the 
heart  is  often  dilated.  The  skin  is  moist  and  diarrhea  is 
common.  A  fine,  rajoid  tremor  of  the  hands  is  almost  al- 
waj's  to  be  observed.  Mental  changes  (irritability,  mania, 
inelancholia)  may  occur.  Far  more  common  in  v^^omen 
than  in  men.  The.  disease  is  apparently  dependent  upon 
excessive  function  of  the  thyroid  gland,  so  it  inay  be  re- 
garded as  the  opposite  of  myxedema. 

Exophthalmic  Goitre. 


THE    PAINS    OF    NERVOUS    DISEASE.  173 


THE   PAINS    OF   NERVOUS    DISEASE. 

I.  Pain  definitely  referred  to  the  distribution   of  one   or   more 
nerves. 

A.  Accompanied  by  signs  of  organic  disease  of  the  nerve, 
such  as  a  tumor  or  tumors  on  the  nerve  trunk  or  nerve 
endings,  atrophic  paralysis,  loss  of  tendon  reflexes  or  of 
faradic  irritability,  tenderness  of  the  nerve  and  the  mus- 
cles supplied  by  it,  sensory  loss  in  the  distribution  of  the 
nerve,  glossy  skin,  etc.  Pain  of  a  peculiar  stinging  or 
burning  character  and  usually  persistent  in  the  interval 
between  exacerbations. 

1 .  No  local  cause  of  neuritis,  such  as  w^ound  or  pres- 
sure. A  tumor  or  tumors  may  be  felt  on  the  nerve 
trunk  or  nerve  endings.  Neurojna. 

2.  A  single  nerve  is  affected  and  a  local  cause  of 
neuritis,  such  as  pressure,  stretching,  a  wound  or 
local  infection,  is  apparent.  Localized  Neuritis. 

3.  The  areas  affected  are  bilateral  and  symmetrical, 
especially  in  the  distribution  of  the  musculo-spiral 
and  external  popliteal  nerves.  A  toxic  cause,  such 
as  alcoholism,  arsenical  poisoning,  general  infection 
or  exposure  with  extreme  exertion  is  present. 

Multiple  Neuritis. 
B .  No  proof  of  organic  disease  of  the  nerve,  although  the  skin 
suppHed  by  it  and  certain  definite  points  along  its  course 
may  be  tender.  Pain  paroxysmal,  usually  with  inter- 
vals of  complete  freedom.  Toxemia,  anemia  or  general 
nervous  depression  and  some  local  irritation  the  most 
common  causes.  Neuralgia. 

II.  Headache.     Pain  in  the  head  not  definitely  referred  to  the 
distribution  of  particular  nerves. 

A.   There  is  organic  disease  of  the  brain  or  its  membranes, 


174  NERVOUS    AND    MENTAL    DISEASES. 

shown,  not  merely  by  the  severity  and  persistence  of  the 
headache,  but  also  by  the  occurrence  of  some  more 
positive  sign,  e.  g.^  paralysis  of  ocular  muscles,  face, 
tongue  or  one  side  of  larynx ;  inequality  of  pupils  or 
failure  of  light  reaction  ;  optic  neuritis  or  optic  atrophy  ; 
typical  ankle  clonus ;  Jacksonian  epilepsy,  etc.  If 
delirium  or  stupor  occurs  headache  still  continues. 
Vomiting  common. 

1.  Onset  sudden  or  very  rapid,  in  a  few^  minutes  to  a 
day,  following  an  injury  or  occurring  in  an  aged  or 
insane  person,  without  fever  or  other  evidence  of  in- 
fection. Rigidity,  perhaps  convulsions,  followed  by 
paralysis,  on  the  side  opposite  the  headache.  Sopor 
and  coma  with  slowness  of  pulse  supervene. 

Meningeal  Hemorrhage. 

2.  Onset  acute  or  subacute,  in  a  few  hours  to  a  few 
weeks.  Delirium,  general  or  local  convulsions  and 
cranial  nerve  symptoms  (such  as  ptosis,  strabismus, 
inequality  or  immobility  of  pupils,  paralysis  or 
twitching  of  face,  etc.)  common.  Optic  neuritis  oc- 
casional, rarely  intense. 

a.  Patient,  more  commonly  a  child  or  an  old  person, 
depressed  by  an  exhausting  disease.  Tempera- 
ture normal  or  slightly  elevated.  Venous  disten- 
sion and  edema  of  the  forehead  and  sides  of  the 
head  or  of  the  eyelids  and  temple. 

Marantic  Sinus  Thrombosis. 

b.  A  source  of  intracranial  infection  or  irritation  is 
present,  e.g..,  otitis  media,  tuberculosis,  pneu- 
monia, epidemic  influence,  wound  of  the 'head, 
sunstroke,  etc.  Fever  attends  the  onset ;  after- 
ward the  temperature  is  irregularly  elevated  or,  at 
times,  depressed.  Retraction  of  the  head  often  a 
prominent  symptom.  Cranial  nerve  symptoms 
common.  Optic  neuritis  occasional,  rarely  in- 
tense. General  hyperesthesia  present  in  the  early 
stage,    followed    by    delirium    which,    in     severe 


THE    PAINS    OF    NERVOUS    DISEASE.  I75 

cases  merges  into  stupor  and  coma.  Whole 
course  from  onset  to  death  or  convalescence  short, 
a  few  hours  to  a  few  weeks. 

Meningitis^  rarely  Encephalitis  or  Abscess. 
i.   The  source  of  infection  is  purulent  otitis  media, 
which  is  followed  by  signs  of  mastoid  disease. 
Then  come  rigors,  rapid  and  extreme  rises  of 
temperature  with  equally  rapid  falls  and  profuse 
sweating,  indicating  pyemia.      The  obstructed 
internal  jugular  vein  may  sometimes  be  felt   in 
the  neck  as  a  cord. 
Thrombosis  of  Lateral  Sinus.     {May  be  as- 
sociated with  meningitis  or  abscess. ) 
Onset  rapid  or  slow,  in  a  few  days  to  weeks  or  months. 
Source    of    purulent    infection    present,   e.g..,   otitis 
media,   empyema,   abscess  in  any  part  of  the  body, 
infected  wound  of  the  head.      Rigors,   followed  by 
fever  and  sweating  common.     Temperature  irregular, 
usually    elevated    but    sometimes    depressed.      Optic 
neuritis  frequent  but  rarely  intense.      In  comparison 
with  menii:igitis  focal  cerebral  symptoms  are  common 
and  cranial  nerve  symptoms  uncommon.      Duration 
may  be  short  or  it  may  be  very  long  with  a  period  of 
latency.  Intracranial  Abscess. 

Onset  slow.  No  signs  of  suppuration.  Tempera- 
ture normal  or  nearly  so.  Headache  usually  intense, 
often  accompanied  by  vertigo  and  vomiting.  Optic 
neuritis  in  four-fifths  of  all  cases,  often  intense. 
Pulse  often  slow.  Course  usually  long  and  for  the 
most  part  steadily  progressive  with  mental  failure 
toward  the  end.  Convulsions  or  any  form  of  focal 
or  cranial  nerve  symptom  may  occur.  Inherited  or 
acquired  predisposition  to  new  growths  sometimes 
apparent. 

Intracranial  Tumor,  Aneurism  or  Cyst. 
Onset  slow,  without  fever  and  without  intense  optic 
neuritis  or  slow  pulse.     Patient  alcoholic  or  syphi- 


176  NERVOUS    AND    MENTAL    DISEASES. 

litic.  Organic  disease  indicated  by  spasm  or  par- 
alysis in  the  domain  of  cranial  nerves,  rarely  in  the 
Hmbs.  Chronic  Meningitis. 

B.  Positive  signs  of  disease  of  the  brain  or  membranes 
absent  but  there  is  evidence  that  the  cerebral  vessels  are 
diseased. 

1.  The  patient  is  past  forty.  The  arteries  are  atherom- 
atous and  pulse  hard.  Headache  is  throbbing  and 
is  increased  by  exertion  or  excitement.  Heart  often 
hypertrophied  and  some  albumen  is  usually  found  in 
the  urine.  Arteriosclerosis. 

2.  Headache  chiefly  nocturnal  and  accompanied  by  in- 
somnia. Age  and  general  condition  exclude  senile 
degeneration.  Syphilis  can  not  be  excluded  and  is 
usually  manifested  by  some  of  its  characteristic  signs. 
Premonitions  of  focal  symptoms  and  rapid  mental 
deterioration,  without  other  assignable  cause  may 
show  that  the  cerebral  circulation  is  greatly  disturbed. 

Syfh  i litic  Enda rteritis. 

C.  Headache  follows  a  blow  on  the  head.  No  positive  signs 
of  organic  disease.  Traumatic  Headache. 

D.  The  headache  forms  part  of  the  periodic  attack  of  mi- 
graine or  epilepsy.  Complete  freedom  between  attacks. 
Family  history  of  similar  attacks  or  of  other  neuroses 
common. 

1 .  Pain  unilateral,  at  least  at  first,  and  accompanied  by 
nausea  and  intolerance  of  light  or  noise,  often  by 
partial  darkening  of  the  field  of  vision  or  subjective 
sensations  of  light  or  color.  Often  complicated  by 
hysteria.  Migraine. 

2.  Headache  precedes  or  follows  an  epileptic  convulsion 
or  an  attack  of  petit  mal.  Epilepsy. 

E.  There  is  no  organic  disease  of  the  brain,  membranes  or 
vessels  and  the  headache  is  not  traumatic  nor  a  part  of  a 
periodic  neurosis. 

I.  Headache  appears  at  the  same  time  as  fever  and 
usually  disappears  if  delirium  supervenes.     There  is 


THE    PAINS    OF    NERVOUS    DISEASE.  177 

evidence  of  a  general  infection,  visually  one  of  the 
specific  fevers.  Meningitis  may  sometimes  be  closely 
simulated,  especially  as  the  pupils  may  be  unequal 
(e. _^. ,  in  pneumonia  or  tonsillitis),  the  head  retracted 
{e.  g-.^  in  typhoid  fever),  or  even  optic  neuritis  be 
present  in  very  rare  cases,  but  other  indications  of 
organic  disease  are  absent.  Infectious  Fever. 

A  toxic  substance  is  active  in  the  system.  Pain  may 
be  diffuse  and  dull  or  in  definite  areas  and  of  a  neu- 
ralgic character. 

a.  The  urine  contains  sugar  and  the  patient  suffers 
from  polyuria,  thirst,  weakness,  etc.        Diabetes. 

b.  The  urine  contains  albumin  or  casts  or  its  specific 
gravity  and  total  quantity  indicate  deficient  elimi- 
nation of  urea.  Pallor  and  edema  are  often 
manifest  and  there  may  also  be  a  characteristic  ret- 
initis. Urei7iia. 

c.  Urine  free  from  albumin  and  sugar,  but  at  times 
is  dark  and  deposits  urates.  Headache  worse  in 
early  morning  and  tends  to  wear  off  during  the 
day;  often  accompanied  by  depression  of  spirits. 
Uric  acid  accumulations  indicated  by  attacks  of 
rheumatism,  gout,  tonsillitis,  gravel,  etc. 

Uric  Acid  Diathesis. 

d.  History  of  excessive  consumption  of  alcohol. 
There  may  be  gastric  catarrh,  morning  vomiting, 
characteristic  odor  of  breath,  tremor,  insomnia, 
etc.  Alcoholism. 

e.  Digestion  is  perverted,  as  shown  by  abdominal 
distress,  eructations,  flatulence  or  other  symptoms. 
Headache  is  usually  dull,  comes  on  soon  after 
eating  or  is  a  sequence  of  eating  some  particular 
food,  and  is  temporarily  relieved  by  purgatives 
and  intestinal  antiseptics.  To  be  distinguished 
from  the  reflex  pain  of  gastric  or  intestinal  disease. 

Indigestion. 

f.  Patient  has  been  exposed  to  lead  which  may  per- 


15 


178  NERVOUS    AND    MENTAL    DISEASES. 

haps  be  found  in  the  urine.  There  may  be  the 
blue  line  on  the  gums,  colic  with  constipation  or 
bilateral  wrist  drop.  Plumbism. 

3.  No  infective  or  toxic  cause  but  the  cerebral  circula- 
tion is  disturbed. 

a.  Headache  throbbing,  follows  excitement  or  exer- 
tion and  may  be  associated  with  a  flushed  face  or 
injection  of  the  conjunctivae.  Increased  by  cough- 
ing, sneezing,  straining  or  lowering  the  head. 

Active  Hyper ejnia. 

b.  Headache  dull  and  heavy.  Return  of  venous 
blood  obstructed  by  mitral  regurgitation,  tumor  of 
the  neck,  constriction  or  other  cause. 

Passive  IIypere?nia. 

c.  Heart  action  weak  or  blood  impoverished,  as 
shown  by  pallor  of  skin  and  mucous  membranes, 
faintness,  low  percentage  of  hemoglobin,  paucity 
of  red  corpuscles,  etc.  Pain  may  be  of  a  neu- 
ralgic character  in  definite  areas.  Anemia. 

4.  No  infective,  toxic  or  circulatory  cause  but  there  is  a 
reflex  disturbance.  The  pain,  accompanied  by  super- 
ficial tenderness,  is  felt  in  definite  areas  and  is 
generally  called  neuralgia. 

a.  There  is  an  error  of  refraction  with  overwork 
of  the  ciliary  muscle,  disease  of  the  eye-ball  or 
rarely  a  loss  of  muscle  balance  alone.  The  pain 
is  mainly  in  the  orbital  region  (e.  ^.,  strain  of  cili- 
ary muscle),  the  fronto-temporal  region  (e.  g.., 
cyclitis)  or  the  temporal  region  (e.  ^. ,  glaucoma), 
sometimes  back  of  the  eye.  In  strain  of  the  ciliary 
muscle  the  pain  appears  in  the  morning,  is  aggra- 
vated by  near  work  and  is  relieved  by  rest  of  the 
eye.      Often  a  complication  of  neurasthenia. 

Ocular  Headache. 

b.  The  pulp  of  one  or  more  teeth  is  diseased  or  the 
teeth  are  crowded  by  a  faulty  eruption.  Reflex 
pain   is   felt   in  the   naso-frontal   area   (upper   in- 


THE    PAINS    OF    NERVOUS    DISEASE. 


179 


cisors),  the  temporal  area  (second  upper  bicus- 
pid) or  one  or  more  of  the  other  pain  areas  of  the 
face  and  neck,   according  to  the   tooth   affected. 

Fig.  25. 


FRONTO-NASAL  AREA.  Af- 
fected by  disease  of  cornea, 
anterior  chamber  of  eye,  up- 
per part  of  nose  and  upper 
incisor  teeth;  sometimes  by 
disease  of  lungs. 


FRONTO-TEMPORAL  AREA. 
Affected  by  iritis  and  glauco- 
ma; sometimes  by  disease  of 
lungs,  aorta  or  cardiac  end  of 
stomach. 


MAXILLARY  AREA.  Affected 
by  iritis,  increased  tension  of 
vitreous  humor  and  disease  of 
2d  upper  bicuspid  tooth  or 
adjacent  part  of  hard  palate. 


MENTAL  AREA.  Affected  by 
disease  of  anterior  part  of 
tongue  and  lower  incisor,  ca 
nine  and  1st  bicuspid  teeth. 


INFERIOR  LARYNGEAL 

AREA.  Affected  by  disease 
of  vocal  cords  and  lower  part 
of  larynx. 


ORBITAL  AREA.  Affected  by 
strain  of  ciliary  muscle  (es- 
pecially in  hypermetropia)  and 
disease  of  the  ciliary  body; 
sometimes  by  disease  of  heart, 
aorta  or  lungs. 


TEMPORAL  AREA.  Affected 
by  glaucoma;  sometimes  by 
disease  of  lungs,  cardiac  end 
of  stomach  or  liver.  Especially 
associated  with  nausea  and 
vomiting. 


MANDIBULAR  AREA.  Af- 
fected by  disease  of  2d  and 
3d  upper  molar  teeth. 


NASO- LABIAL  AREA.  Af- 
fected by  disease  of  respira- 
tory portion  of  nose  and  upper 
canine  and  1st  bicuspid  teeth. 


SUPERIOR  LARYNGEAL 

AREA.  Affected  by  disease 
of  upper  part  of  larynx,  pos- 
terior part  of  tong.ue  and  3d 
lower  molar  tooth. 


Areas  of  reflex  or  referred  pain  according  to  the  researches  of  Henry  Head. 


Generally  described  as  neuralgia,  although  the  areas 
of  pain  do  not  sti'lctly  correspond  to  the  distribu- 
tion of  individual  nerves.  Dental  Headache. 
There  is  disease  of  the  tympanic  cavity  or  drum 


i8o 


NERVOUS    AND    MENTAL    DISEASES. 


OCCIPITAL  AREA.    Affected  ^ 
by  disease  of  posterior  part  of 
dorsum  of  tongue,  kidney,  ure- 
ter, ovary,  testicle  and  pros 
tate  gland 


membrane.      The  pain  is  most  intense  in  the  ear 
and  back  of  the  angle  of  the  jaw,  but  may  extend 

Fig.  26. 

VERTICAL  AREA  Affected 
by  disease  of  posterior  part  of 
eye,  increased  tension  of  mid- 
dle ear  and  disease  of  stom- 
ach or  liver. 


FRONTO-TEMPORAL  AREA. 
Affected  by  iritis  and  glauco- 
ma ;  sometimes  by  disease  of 
lungs,  aorta  or  cardiac  end  of 
stomach. 


FRONTO-NASAL  AREA.  Af- 
fected by  disease  of  cornea, 
anterior  chamber  of  eye,  up- 
per part  of  nose  and  upper 
incisor  teeth;  sometimes  by 
disease  of  lungs. 


HYOID  AREA.  Affected  by 
disease  of  middle  ear  or  drum 
membrane,  tonsil,  middle  por- 
tion of  tongue,  and  1st  and  2d 
lower  molar  teeth. 


MAXILLARY  AREA.  Affected 
by  iritis,  increased  tension  of 
vitreous  humor  and  disease  of 
2d  upper  bicuspid  tooth  or 
adjacent  part  of  hard  palate. 


MENTAL  AREA.  Affected  by 
disease  of  anterior  part  of 
tongue  and  lower  incisor,  ca- 
nine and. 1st  bicuspid  teeth, 


INFERIOR  LARYNGEAL 

AREA.  Affected  by  disease 
of  vocal  cords  and  lower  part 
of  larynx. 


Areas  of  reflex  or  referred  pain'according'to  the  researches  of  Henry  Head. 


over  the  vertical  and  parietal  areas. 

Aural  Headache. 

i.   Purulent  otitis  is  follow^ed  by  mastoid  disease 

and  then  by  signs  of  pyemia.      The  obstructed 


THE    PAINS    OF    NERVOUS    DISEASE. 


I»I 


jugular  vein  may  sometimes  be  felt  in  the  neck 
as  a  cord. 

Throntbosis  of  Lateral  Sinus.     {May  exist 
■with  or  without  meningitis  or  abscess.) 
d.   The  pain  is  felt  in  the  fronto-nasal  or  orbital  area 

Fig.  27. 


PARIETAL  AREA.  Affected 
by  disease  of  middle  ear  and 
pyloric  end  of  stomach. 


MANDIBULAR  AREA.  Af- 
fected by  disease  of  2d  and 
3d"  upper  molar  teeth. 


ORBITAL  AREA.  Affected  by 
strain  of  ciliary  muscle  les- 
pecially  in  hypermetropia)  and 
disease  of  the  ciliary  body; 
sometimes  by  disease  of  heart, 
aorta  or  lungs. 


TEMPORAL  AREA.  Affected 
glaucoma;  sometimes  by  dis- 
ease of  lungs,  cardiac  end  of 
stomach  or  liver. 


NASO- LABIAL  AREA.  Af- 
fected by  disease  of  respira- 
tory portion  of  nose  and  upper 
canine  and  1st  bicuspid  teeth. 


SUPERIOR  LARYNGEAL 

AREA.  Affected  by  disease 
of  upper  part  of  larynx,  pos- 
terior part  of  tongue  and  3d 
lower  molar  tooth. 


Areas  of  reflex  or  referred  pain  according  to  the  researches  of  Henry  Head. 


l82  NERVOUS    AND    MENTAL    DISEASES. 

and  is  associated  with  disease  of  the  nose  or  its 
adjacent  sinuses,  increasing  or  diminishing  with 
it.  Headache  may  sometimes  be.  markedly  in- 
creased by  touching  the  middle  turbinated  bone 
with  a  probe  and  relieved  by  the  application  of 
cocaine.      Rare.  Nasal  Headache. 

e.   The  headache  is  added  to  pain  and  tenderness  in 
the  sensory  areas  of  certain  spinal  segments  (Figs. 
38   and   29)    as  a  secondary   reflex    pain,    due  to 
disease  of  some  of  the  viscera  within  the  trunk, 
i.   Aortic  regurgitation,  aortic  aneurism  or  mi- 
tral  stenosis  with   I'egurgitation   is   present. 
Headache  in  the  forehead  or  temple,  mainly 
on  the   left    side.     Pain   and    tenderness    in 
some  of  the  areas  of  the  first  six  dorsal  seg- 
ments, often  subject  to  severe  exacerbations 
(angina  pectoris).  Cardiac  Headache. 

ii.  Active  pulinonary  disease  exists.  Headache 
may  be  in  any  part  of  the  cranivim,  except 
the  occiput,  mainly  on  the  side  of  the  dis- 
ease. Pain  and  tenderness  in  some  of  the 
areas  of  the  first  seven  dorsal  segments. 

Pulmonary  Headache. 
iii.   A  painful  disease  of  the  stomach  exists.  Head- 
ache in  the  temporal,  vertical  or  parietal  re- 
gion.    Pain  and  tenderness  in  some  of  the 
areas  of  the  sixth  to  ninth  dorsal  segments. 
Gastric  Headache. 
iv.  An  irritating  disease  of  the  intestine  exists. 
Headache    parietal  or   occipital.     Pain  and 
tenderness  in  some  of  the  areas  of   the  ninth 
to  twelfth  dorsal  segments. 

Intestinal  Headache. 
V.   There  is  disease  of  the  liver  or  its  appendages. 
Headache  temporal,  vertical,  parietal  or  oc- 
cipital.    Pain  and  tenderness  in  some  of  the 
areas  of  the  seventh  to  tenth  dorsal  segments. 
Hepatic  Headache. 


THE    PAINS    OF    NERVOUS    DISEASE.  183 

vi.  There  is  a  painful  disease  of  the  kidney  or 
ureter,  most  frequently  calculus.  Headache 
occipital.  Pain  and  tenderness  in  some  of  the 
areas  of  the  tenth  to  twelfth  dorsal  segments. 

Renal  Headache. 

vii.   There  is  disease  of  the  prostate.      Headache 

occipital.      Pain  and  tenderness   in   some  of 

the  areas  of  the  tenth  to  twelfth  dorsal,  first 

lumbar  or  first  to  third  sacral  segments. 

Prostatic  Headache. 
viii.   The  ovary  or  testicle  is  diseased.      Headache 
occipital.     Pain    and    tenderness   in    area  of 
tenth  dorsal  segment. 

Ovarian  or  Orchitic  Headache. 
5.   No    infective,  toxic,   circulatory  or  reflex   cause  ap- 
parent. 

a.  Nervous  energy  exhausted  from  any  cause,  par- 
ticularly by  prolonged  worry  with  overwork  or 
other  excess  combined  with  impaired  nvitrition. 
The  patient  may  for  a  short  time  exert  normal 
mental  and  bodily  powers,  but  soon  becomes  fa- 
tigued and  irritable.  Sensations  in  the  head  are 
often  described  as  queer  and  disagreeable  rather 
than  painful,  such  as  tightness  or  looseness  of  the 
scalp,  lightness,  heaviness  or  increased  volume  of 
the  head,  inability  to  think,  etc.  A  lack  of  zest 
for  ordinary  affairs  and  morbid  fears  are  common. 
Painful  and  superficially  tender  spots  are  usually 
found  along  the  spine  as  well  as  in  the  head. 

JVctir  asthenia. 

b.  Headache  appears  and  disappears  in  accord  with 
emotional  changes  or  in  response  to  suggestion. 
Often  limited  to  a  small  spot  at  vertex  or  in  tem- 
ple (clavus).  Various  signs  of  hysteria  may  be 
present.  Hysteria. 

III.  Spinal  pain.  Pain  felt  in  or  near  the  spinal  column,  often 
extending  into  the  sensory  areas  supplied  by  the  correspond- 
ing segments  of  the  spinal  cord. 


184  NERVOUS    AND    MENTAL    DISEASES. 

A.  Accompanied  by  signs  of  organic  spinal  disease,  such  as 
deformity  of  the  spine ;  absence  of  knee-jerk  ;  typical 
clonus ;  degenerative  atrophy  of  muscles  with  loss  of 
faradic  irritability  (without  signs  of  neuritis)  ;  the  com- 
bination of  paraplegia  with  more  or  less  sensory  loss, 
the  upper  limit  of  both  corresponding  to  the  function  of 
a  spinal  segment ;    impaired  control  of  the  bladder,  etc. 

1.  Paraplegia,  more  or  less  sensory  loss  and  impaired 
control  of  the  bladder  and  rectum  appear  early.  The 
upper  limit  of  the  motor  and  sensory  loss  corres- 
ponds to  the  function  of  a  segment  of  the  spinal  cord 
and  is  often  marked  by  a  zone  of  hyperesthesia  im- 
mediately above  it.  Spinal  rigidity  and  radiating 
pains  generally  absent. 

a.  Onset  sudden. 

i.   Simultaneous  with  severe  injury  to  the  spinal 
column. 

Frachire    or     Dislocation     of     Vei'tebrce^ 
Wound    of    01'     Hemorrhage    into     the 
Spinal  Cord. 
ii.   Without  external  violence. 

Hemorrhage  into  Cord. 

b.  Onset  gi^adual,  acute  or  chronic.      Vertebrae  not 
diseased.      Pain  dull,  not  a  prominent  symptom. 

Myelitis. 

2.  Spinal  rigidity  accompanies  pain.  Corresponding 
radiating  pains  common.  If  paraplegia,  sensory 
loss  and  impaired  control  of  the  bladder  and  rectum 
occur,  it  is  later  in  the  course  of  the  disease. 

a.   Deformity  or  swelling  and  deep-seated  tenderness 
indicate  disease  of  the  vertebras.      Paraplegia,  sen- 
sory loss  and  impaired  control  of  bladder  and  rec- 
tum eventually  occur  unless  the  disease  is  arrested. 
i.   Patient  most  commonly  a  child,  sometimes  a 
young  adult,  rarely  an  elderly  person.      The 
tubercular  diathesis  is  generally  m.anifest  but 
.     very  rarely  syphilis  may  be  the  cause.      Pain 


Fig.  2S. 


CJV 


C.V7. 


Diagram  of  Skin  Areas  Corresponding  to  Different  Spinal  Segments 
(From  Tyson,  after  Starr.     Trunk  Areas  from  Head.) 

16 


Fig.  29. 


cn 


Diagram  of  Skin  Areas  Corresponding  to  Different  Spinal  Segments. 

Arabic  Numerals  refer  to  Vertebrae.    (From  Tyson,  after 

Starr.     Trunk  Areas  from  Head.) 


THE    PAINS    OF    NERVOUS    DISEASE.  187 

usually    of    moderate    severity,    increased    by 
motion  or  jars  and  diminished  by  rest  of  the 
spine.      Prominence  or  lateral  displacement  of 
one  or  more  spinous  processes  is  the  character- 
istic deformity.  Spinal  Carles. 
ii.   Patient    generally  in  the  second  half  of    life, 
sometimes  with  a  history  of  tumor  elsewhere 
or  of  predisposition  to  new  growths  or  aneur- 
ism.     The   pain   is   very  intense   and   is  very 
greatly  aggravated  by  motion. 
§   The  radiating  pain  is  on  the  left  side  of 
the  chest.       Characteristic  thrill  and  mur- 
mur at  the  seat  of  pain  and  deformit}^ 

Aneurism  Eroding  Spine. 

§§   Radiating  pain  usually  on  both  sides.     No 

thrill  or  murmur.  Spinal  Tumor. 

b.  Localized  spinal  pain  and  rigidity  gradually  occur, 
most  frequently  in  the  cervical  region,  in  a  patient 
predisposed  to  arthritis  deformans,  evidence  of 
which  may  be  apparent  in  other  parts  of  the  body. 
Radiating  pains  and  other  root  symptoms  may 
occur  but  are  not  followed  by  paraplegia  or  other 
cord  symptoms.      Rare. 

Vertebral  Arthritis  Deformans. 

c.  Nothing  to  indicate  disease  of  the  vertebrae. 

i.   Onset  sudden.     No  fever  at  first. 

Spinal  j\Ie7ilngeal  Hem.orrhage. 
ii.   Onset  acute,  marked  by  chill  and  fever. 

Acute  Spinal  Meningitis . 
iii.   Onset  chronic. 

§   History  of  alcoholism,  syphilis  or  exposure 
to  cold.  Chronic  Spinal  Meningitis. 

§§   Evidence  of  predisposition  to  new  growth. 
No  other  cause  of  meningitis. 

Intraspinal  Tum,or. 
B.   Not  accompanied  by  signs  of  organic  spinal  disease. 
I .  Pain  and  superficial  tenderness  in  the  back  and  in  the 


NERVOUS    AND    MENTAL    DISEASES. 

sensory  areas  of  corresponding  segments  appears  in 
connection  with  visceral  disease  and  increases  or  di- 
minishes with  it,  constituting  the  referred  or  reflex 
pain  of  visceral  disease.  The  correspondence  of  the 
painful  areas  to  the  particular  organ  diseased  is  shown 
in  the  following  table,  -which  is  taken  from  the  work 
of  Dr.  Henry  Head.  It  must  be  remembered,  how- 
ever, that  febrile  and  toxic  conditions  without  demon- 
strable localized  disease  may  cause  the  same  areas  to 
become  painful.      Often  called  neuralgia. 


ORGAN   DISEASED. 


Heart, 
Lungs, 


SPINAL  SEGMENTS  WHOSE  SENSORY 
AREAS  ARE  PAINFUL. 

1,2,3  dorsal  (angina  pectoris), 
3,4  cervical,  i,  2,  3,  4,  5  dorsal. 


Ascending  Aorta,   i,  2,  3,  4  dorsal. 


Arch  of  Aorta, 
Stomach,  cardiac, 
Stomach,  pyloric, 
Liver  and  append- 
ages, 
Intestine, 
Kidney  and  ureter, 
Prostate, 

Ovary  or  testicle. 

Rectum, 

Epididymis, 

Oviduct, 

Bladder,  mucous 
membrane  and 
neck, 

Bladder,  over-dis- 
tension and  in- 
effectual con- 
traction. 

Uterus,  in  con- 
traction , 

Uterus,  OS, 


5,  6  dorsal, 

6,  7  dorsal, 

8,  9  dorsal, 

7,  8,  9,  10  dorsal, 

9,  10,  II,  12  dorsal, 

10,  II,  12  dorsal, 

10,  II,  12  dorsal,  5  lumbar,  i, 
2,  3  sacral, 

10  dorsal, 
2,  3,  4  sacral. 

11,  12  dorsal. 

II,  12  dorsal,  i  lumbar. 


I,  2,  3,  4  sacral. 


II,  12  dorsal,  i  lumbar. 

ID,  II,  12  dorsal,  i  lumbar. 
I,  2,  3,  4  sacral  (5  lumbar  very 
rarely). 


CRANIAL  AREAS  IN  WHICH 
PAIN  MAY  ALSO  BE  FELT. 

Orbital. 

Fronto-nasal,  orbital, 
fronto-temporal,  tem- 
poral. 

Orbital,  fronto-tem- 
poral. 

Fronto-temporal. 

Fronto-temp.,  temporal. 

Vertical,  parietal. 

Temporal,  vertical,  pa- 
rietal, occipital. 

Parietal  occipital. 

Occipital. 

Occipital. 

Occipital. 


THE    PAINS    OF    NERVOUS    DISEASE.  189 

2.  The  pain  is  most  frequently  in  the  lumbar,  some- 
times in  the  dorsal  or  cervical  region,  and  is  gen- 
erally worse  in  the  morning,  tending  to  wear  off 
during  the  day.  There  is  evidence  of  a  rheumatic 
condition,  such  as  rheumatism  in  other  parts  of  the 
body,  a  history  of  previous  rheumatic  attacks,  marked 
variations  corresponding  to  changes  in  the  weather, 
the  alternation  of  scanty  and  excessive  elimination  of 
urates,  great  relief  from  the  administration  of  salicy- 
lates, etc.  Not  a  nervous  disease,  but  included  here 
because  it  must  often  be  carefully  distinguished  from 
more  serious  diseases  which  are  likely  to  be  mistaken 
for  it.  Rheumatisjn. 

3.  There  are  moderately  painful  and  superficially  tender 
spots  along  the  spine  and  often  in  the  head.  Ner- 
vous energy  is  exhausted  from  some  cause,  usually 
by  prolonged  worry  w^ith  overwork  or  other  excess 
combined  with  impaired  nutrition.  The  patient 
may  for  a  short  time  exert  normal  mental  and  bodily 
powers  but  soon  becomes  fatigued  and  irritable. 
Queer  sensations  in  the  head  are  often  complained 
of,  such  as  tightness  or  looseness  of  the  scalp,  light- 
ness, heaviness  or  increased  volume  of  the  head,  in- 
ability to  think,  etc.  Morbid  fears  and  a  lack  of 
interest  in  ordinary  affairs  are  common. 

Neurasthenia. 

4.  The  pain  comes  and  goes  in  accord  with  emotional 
changes  or  in  response  to  suggestion.  Although  it 
and  the  accompanying  superficial  tenderness  may 
appear  to  be  intense,  both  disappear  or  are  greatly 
diminished  ^vhen  attention  is  strongly  engaged  by 
something  else.  Various  other  signs  of  hysteria  may 
be  present.      Often  combined  with  neurasthenia. 

Hystei'ia. 
IV.  Pain  felt  in  the  trunk  or  extremities  not   accompanied   by 
corresponding  spinal  pain  nor  definitely  referred  to  the  dis- 
tribution of  certain  nerve  trunks. 


ipO  NERVOUS    AND    MENTAL    DISEASES. 

A.  There  are  signs  of  organic  disease  of  the  brain  or  cord. 

1 .  The  patient  has  suffered  a  cerebral  vascular  lesion, 
most  frequently  softening  in  the  region  of  the  basal 
ganglia  and  the  pain  is  due  to  irritation  of  the  sen- 
sory tract.  Post-Jiemiplegic  Pain. 

2.  The  pain  consists  of  lightning  pains  in  the  lower 
limbs  or  trunk,  or  has  the  character  of  "crises" 
(gastric,  laryngeal,  vesical,  rectal,  etc.).  Absence 
of  knee-jerk  with  Argyll-Robertson  pupil,  ataxia  or 
urinary  difficulty  makes  the  diagnosis  clear.      Tabes. 

3.  Pain  may  be  like  that  of  neuralgia  or  that  of  tabes. 
-     There  is  loss  of  sensibility  to  temperature  and  pain 

w^ith  preservation  of  touch.  More  or  less  paralysis 
occurs,  usually  atrophic  in  the  arms  and  spastic  in 
the  legs,  together  with  various  trophic  symptoms,  the 
vs^hole  group  of  symptoms  being  such  as  might  be 
caused  by  chronic  disease  mainly  affecting  the  gray 
matter  of  the  cord.  Syringomyelia. 

B.  There  are  no  signs  of  organic  disease  of  the  brain  or 
cord . 

1 .  Pain  caused  by  arrest  of  circulation,  which  is  usually 
in  the  extremities  (fingers,  toes,  nose,  ears)  and 
symmetrical,  but  is  sometimes  unsymmetrical  and  may 
affect  the  trunk  and  proximal  parts  of  limbs.  The 
disease  begins  with  local  pallor  and  a  feeling  of  icy 
coldness  (local  syncope),  w^hich,  after  a  variable 
time,  is  followed  by  cyanosis  (local  asphyxia)  and 
later  by  gangrene.  The  symptoms  are  aggravated  by 
cold  and  relieved  by  warmth.  In  the  cyanotic  and 
gangrenous  stages  the  pain  may  be  intense. 

Raynaud's  Disease. 

2.  Pain  in  one  foot,  very  rarely  in  both  feet  or  in  a 
hand,  associated  with  redness  and  often  -with  swell- 
ing and  increased  local  temperature,  sometimes  with 
hyperhidrosis  and  local  hemorrhages.  All  the  symp- 
toms tend  to  subside  when  the  patient  reclines  and 
supports  the  extremity  in  an  elevated  position ;   they 


THE    PAINS    OF    NERVOUS    DISEASE.  I9I 

ai'e  also  relieved  b}-  cold  and  aggravated  by  warmth. 
Standing  erect  and  letting  the  extremity  hang  brings 
on  paroxysms  of  pain  accompanied  by  a  rose-red 
flush  and  arterial  throbbing;  there  is  no  cyanosis 
or  gangrene.  Occurs  mostly  in  men  either  alone  or 
in  association  with  various  other  nervous  affections. 

Erythromelalgia . 
The  pain  comes  and  goes  in  accord  with  emotional 
changes  or  in  response  to  suggestion.  Although  it 
and  the  accompanying  superficial  tenderness  may 
appear  to  be  intense,  both  disappear  or  are  greatly 
diminished  when  attention  is  strongly  engaged  by 
something  else.  Various  other  signs  of  hysteria  may 
be  present.      Often  combined  with  neurasthenia. 

Hysteria. 
a.  The  pain  is  felt  in  a  joint,  most  commonly  the  hip, 
knee,  shoulder  or  ankle,  and  the  complaints  are  out 
of  all  proportion  to  any  objective  signs  of  disease. 
Night  startings,  involuntary  cries  and  facial  signs 
of  severe  suffering  ai'e  absent.  The  joint  may  be 
held  in  a  fixed  position  by  spasm  of  its  muscles, 
but  this  spasm  relaxes  more  or  less  during  sleep 
and  may  often  be  entirely  overcome  by  persistent 
moderate  force  if  the  patient's  attention  can  be  dis- 
tracted. The  muscles  are  not  wasted  more  than 
disuse  w^ould  account  for  and  their  electrical  irri- 
tability is  normal.  The  local  temperature  is  gener- 
ally normal  or  sub-normal ;  rarely  it  is  temporarily 
elevated,  never  persistently  so.  The  posture  often 
differs  widely  from  that  of  greatest  ease  and  in 
many  cases  automatic  actions  which  would  cause 
great  pain  in  real  joint  diseases  ai'e  performed  with- 
out complaint.  The  symptoms  often  change  greatly 
within  a  short  time.  Examination  under  anesthesia 
reveals  no  sign  of  joint  disease. 

Hysterical  Simulation  of  Joint  Disease. 


192  NERVOUS    AND    MENTAL    DISEASES. 


VERTIGO. 

The  patient  has  a  false  sense  of  motion  of  his  own  body 
or  of  the  objects  about  him.  The  sensation  may  be  so 
strong  as  to  cause  actual  motion  of  the  body  in  the  same 
direction. 

I.  There  is  coarse  organic  disease  of  the  brain  or  its  mem- 
branes, generally  shown  by  headache  and  voiniting  (not  de- 
pendent on  the  vertigo),  together  with  such  symptoms  as 
hemiplegia ;  paralysis  of  ocular  muscles,  face,  tongue  or  one 
side  of  larynx ;  inequality  of  pupils  or  failure  of  light  reac- 
tion ;  optic  neuritis  or  optic  atrophy  ;  typical  ankle  clonus  ; 
Jacksonian  epilepsy ;  coincident  mental  impairment,  etc. 
The  localizing  symptoms  generally  indicate  the  cerebellum, 
pons  or  quadrigeminum  as  the  seat  of  lesion. 

Vertigo  of  Organic  Intracranial  Disease^  special  diag- 
nosis to  be  made  as  in  cases  of  hemiplegia,  optic  neu- 
ritis, headache,  etc. 
II.   There  is  degenerative  disease  of  the  central  nervous  system, 
shown  by  its  very  slow  onset  and  the  presence  of  such  symp- 
toms as  ataxia,  intention  tremor,  ocular  paralysis,  nystagmus, 
optic  atrophy,  Argyll-Robertson  pupil,  loss  or  great  exag- 
geration of  knee-jerks,  slight  urinary  difficulty,  stumbling  or 
scanning  speech  and  characteristic  mental  impairment. 

A.  The  gait  and  station  are  ataxic,  especially  when  the  eyes 
are  closed,  and  the  knee-jerks  are  absent.  A  history  of 
lightning  pains  in  the  legs  is  common,  also  of  loss  of 
virility,  slight  urinary  difficulty  and  ptosis  or  diplopia. 
Argyll -Robertson  pupil  in  most  cases.  Tabes. 

B.  Intention  tremor  v\^ith  nystagmus  or  scanning  speech  is 
associated  with  various  signs  of  scattered  lesions,  such 
as  isolated  paralyses,  contraction  of  the  visual  fields  with 


VERTIGO.  193 

impairment  of  color  sense,  loss  of  smell,  nervous  deaf- 
ness, etc.  Disseminated  Sclerosis. 
C.  Failure  of  judgment  and  memory,  often  combined  with 
monstrous  and  unsystematized  delusions  of  grandeur, 
accompanies  signs  of  organic  disease,  among  which  in- 
equality of  pupils,  facial  twitching  and  stumbling  speech 
are  common.  Paretic  Dejnentia. 

III.  Positive  signs  of  organic  disease  of  the  brain  or  membranes 
absent,  but  there  is  evidence  that  the  cerebral  vessels  are 
diseased. 

A.  The  patient  is  past  forty.  The  arteries  are  atheroma- 
tous and  pvdse  hard.  Vertigo  often  accompanied  by 
throbbing  headache  which  is  increased  by  exertion  or 
excitement.  Heart  often  hypertrophied  and  some  albu- 
men may  be  found  in  the  urine. 

A  rteriosclerosis. 

B.  Age  and  general  condition  exclude  senile  degeneration. 
Nocturnal  headache  and  insomnia  generally  present. 
History  or  physical  condition  or  mental  deterioration 
without  other  assignable  cause  gives  evidence  of 
syphilis.  Syphilitic  Endarteritis. 

IV.  There  is  no  organic  disease  of  brain,  membranes  or  vessels. 

A.  The  vertigo  follows  a  blow  on  the  head  and  may  persist 
after  all  other  symptoms  have  disappeared.      Concussion. 

B.  The  vertigo  follows  rotary,  swinging  or  vertical  motion 
of  the  body,  as  in  sea-sickness.       Mechanical  Vertigo. 

C.  There  is  a  toxic  cause,  as  in  cases  of  over-consumption 
of  alcohol,  tobacco,  caffein  or  other  drugs,  or  of  auto- 
intoxication as  by  uric  acid,  urea  or  ptomaines. 

Toxic   Vertigo. 

D.  Vertigo  occurs  in  paroxysms,  in  association  with  tinnitus 
and  deafness  which  are  shown  to  be  nervous  by  impair- 
ment of  bone  conduction  and  limitation  of  the  auditory 
field  for  high  notes.  Lesions  of  the  middle  or  external 
ear  may  coexist  and  in  some  cases  they  are  the  primary 
cause  of  the  labyrinthine  disease.  Paroxysms  are  some- 
times excited  by  coughing,  sneezing,  a  loud  noise,  indi- 


194  NERVOUS    AND    MENTAL    DISEASES. 

gestion  or  any  depressing  influence,  and  ma)'  be  severe 
enough  to  hurl  the  patient  to  the  ground.  Between 
paroxysms  vertigo  may  be  entirely  absent  or  present  in  a 
slighter  degree,  but  deafness  and  usually  some  tinnitus 
persist.  Nystagmus,  diplopia,  vomiting  and  severe 
prostration  may  be  secondary  consequences  of  an  attack. 
A  disease  of  adult  life,  twice  as  frequent  among  men  as 
among  women. 

Labyrinthiite  Vertigo  (including  Meniere's  Dis- 
ease). Subacute  and  chronic  inflammation  and 
degeizeration  dtie  to  cold.,  gout.,  syphilis  or  senility 
are  the  common  conditions ;  hemorrhage  and 
acute  injlarnmation  are  very  rare. 

E.  Weakness  of  one  or  more  ocular  muscles  causes  an 
erroneous  projection  of  the  visual  field.  Vertigo  dis- 
appears on  closing  the  eyes  or  on  restoration  of  the 
muscle  balance.  Usually  transient  owing  to  the  re- 
education of  the  sensory  centers  involved.  Compara- 
tivelv  rare.  Ocular    Vertigo. 

F.  Vertigo  is  preceded  by  indigestion  and  disappears  when 
the  indigestion  is  cured.  Organic  disease  of  the  labyrinth 
excluded.  Gastric   Vertigo. 

G.  Vertigo  is  associated  with  disease  of  the  nose  or  adjacent 
sinuses  and  increases  or  diminishes  with  it,  sometimes 
being  relieved  by  an  application  of  cocaine.  The  laby- 
rinth is  not  organically  diseased,  but  is  probably  dis- 
turbed owing  to  an  intimate  relation  between  the  nasal 
and  labyrinthine  vessels.      Very  rare.       Nasal  Vertigo. 

H.   The  cerebral  circulation  is  disturbed. 

1.  Vertigo  associated  with  throbbing  in  the  head,  per- 
haps with  flushing  of  the  face  and  injection  of  the 
conjunctivae.  Increased  by  coughing,  sneezing, 
straining  or  lowering  head.  Active  Hyperemia. 

2.  Associated  with  dull,  heavy  feeling  in  head.  Return 
of  venous  blood  obstructed  by  mitral  regurgitation, 
tumor  of  the  neck,  constriction  or  other  cause. 

Passive  Hyperemia. 


VERTIGO.  195 

3,   Heart   action  is  weak  or  impoverishment  of  blood  is 

shown  by  pallor  of  skin  and  mucous  membranes,  faint- 

ness,  low  percentage  of  hemoglobin  or  paucity  of  red 

corpuscles.  Cerebral  Anemia. 

I.   Vertigo   occurs  as   part  of    a   periodic   nervous   attack, 

disease  of  the  labyrinth  being  excluded. 

1.  The  vertigo  occurs  as  the  aura  of  an  epileptic  con- 
vulsion or,  together  with  a  brief  interruption  of  con- 
sciousness, constitutes  an  attack  of  petit  mal. 

Epileptic   Vertig'o. 

2.  The  vertigo  is  part  of  periodic  attacks  in  which 
unilateral  headache,  nausea,  intolerance  of  light  and 
noise,  and  partial  darkening  of  the  visual  field  or  sub- 
jective perception  of  light  are  common.  Rarely  it 
may  constitute  the  whole  of  an  attack. 

Migrai^ious  Vertigo. 

3.  The  earlier  attacks  have  an  emotional  cause  and 
afterwards  may  occur  or  be  suppressed  in  consequence 
of  an  emotional  change  or  a  suggestion.  Various 
signs  of  hysteria  may  be  present.  Hysterical  deaf- 
ness and  tinnitus  may  be  so  associated  as  to  closely 
simulate  labyrinthine  disease.        Hysterical  Vertigo. 

J.  The  patient's  nervous  energy  has  been  exhausted,  especi- 
ally by  prolonged  worry  with  or  without  overwork.  He 
can  generally  exert  normal  bodily  and  mental  powers  for 
a  short  time  but  is  soon  fatigued  and  is  more  or  less 
irritable.  Unreasonable  fears  are  common.  Painful  or 
tender  spots  in  the  head  or  along  the  spine  (found  to  be 
of  shifting  location  if  accurately  marked)  are  very  com- 
mon. Other  morbid  sensations  in  the  head  are  often 
described  as  queer  rather  than  painful,  such  as  tightness 
or  looseness  of  the  scalp,  heaviness,  lightness,  emptiness 
or  dullness  of  the  head,  etc.  Neurasthenia. 

K.   No  sufhcient  cause  can  be  found. 

'•'-Essential  Vertigo^''  most  probably  a  symptom  of 
beginning  disease  of  the  labvrinth  or  of  an  undetected 
accumulation  of  uric  acid. 


196  NERVOUS    AND    MENTAL    DISEASES. 


COMA. 

The   patient  is  unconscious    and  a    satisfactory  history 
cannot  be  obtained. 

I.  The  head  has  been  injured. 

A.  Skuh  generaUy  unfractured.  No  paralysis.  Coma  not 
profound.  Patient  tosses  about.  Pupils  contracted. 
Pulse  rapid.      Breathing  quiet.      Reflexes  retained. 

Cerebral  Concussion. 

B.  Skull  often  fractured.  There  is  unilateral  paralysis 
often  with  conjugate  deviation  of  head  and  eyes,  or  there 
is  relaxation  on  both  sides  of  the  body.  Coma  profound. 
Pupils  dilated,  often  unequal.  Pulse  slow.  Breathing 
stertorous.  Superficial  reflexes  lost  or  diminished,  es- 
pecially on  the  paralyzed  side,  and  all  reflexes  may  be 
abolished. 

Cerebral  Co7fipresston,  due  to  hemorrJtage.^  usually 
meningeal. 
11.   Careful  exaiuination   reveals   no   evidence  of    injury  to  the 
head. 

A.  There  is  unilateral  paralysis,  often  with  conjugate  devia- 
tion of  head  and  eyes.     Pupils  may  be  unequal. 

Diagnosis  as  in  Hemiplegia. 

B.  No  paralysis  or  other  sign  of  unilateral  cerebral  lesion. 

1.  Heart  very  feeble.  Respiration  shallow.  Skin 
pale  and  cold.  There  may  be  evidence  of  loss  of 
blood.  Consciousness  quickly  returns  if  the  cere- 
bral circulation  is  restored.  Syncope. 

2.  Urine  albuminous  and  contains  casts  or  is  scanty 
and  of  low  specific  gravity.  There  may  be  charac- 
teristic pallor  and  edema  or  retinitis.  Eclampsia 
may    occur.       Breath    may    have    a    urinous    odor. 


COMA.  197 

Temperature  generally  depressed  except  in  puerperal 
cases.  Uremia. 

3.  Urine  contains  a  considerable  quantity  of  sugar. 
Breath  may  have  the  odor  of  acetone.         Diabetes. 

4.  Diminution  of  hepatic  dullness,  enlargement  of 
spleen,  sallowness,  emaciation  and  ascites  or  other 
sign  of  portal  obstruction  present.      No  other  cause. 

Cirrhosis  of  Liver. 

5.  Pupils  contracted.  Respiration  weak  and  slow. 
Pulse  generally  strong.  Narcotic  odor  of  breath  or 
the  surroundings  may  indicate  that  opium  or  one  of 
its  preparations  has  been  taken. 

Opium  Poisoning. 

6.  Respiration  weak  and  slow.  Pulse  weak,  perhaps 
rapid  or  irregular.  Contents  of  stomach  heated  with 
caustic  potash  or  soda  give  odor  of  chloroform. 

Chloral  Poisoning. 

7.  Odor  of  carbolic  acid.  Mucous  membrane  of  mouth 
whitened  and  shrivelled.  Urine  may  be  greenish 
black.  Phenol  Poisoning. 

8.  Coma  not  profound.  Odor  of  alcohol  on  breath. 
Temperature  normal  or  subnormal.     Drunkenness. 

9.  Patient  has  been  exposed  to  extreme  heat  in  a  moist 
atmosphere.     Bodily  temperature  very  high. 

Heat-stroke. 
10.   All  the  above  causes  absent.     Tongue  may  be  bitten. 
Convulsion  may  be  known  to  have  accompanied  on- 
set of  coma,  which  does  not  last  long  unless  convul- 
sion recurs.     Patient  generally  in  first  half  of  life. 

Epilepsy. 
N.  B.   Many  other  conditions  cause  coma,  especially  just  be- 
fore death,  but  the  history  is  generally  known  and  the  diagnosis 
made  from  earlier  symptonis. 


198  NERVOUS    AND    MENTAL    DISEASES. 


DISORDERS    OF    SPEECH. 

I.  Words  are  badly  uttered  owing  to  defect  in  the  movements 
of  the  vocal  organs,  but,  considering  the  age  and  education 
of  the  patient,  are  not  defective  in  number  or  arrangement. 
The  understanding  of  spoken  words  and  reading  and  writing 
are  not  affected. 

A.  The  patient  speaks  only  in  a  whisper  and  the  vocal  cords 
cannot  be  voluntarily  brought  together,  although  they  ap- 
proximate perfectly  in  coughing  or  sneezing.  Whis- 
pered articulation  is  generally  good,  but  the  aphonia  may 
pass  into  mutism.  Onset  usually  sudden  in  an  hysterical 
attack  or  after  violent  emotion,  but  may  be  gradual. 
Other  signs  of  hysteria  always  present. 

Hysterical  Aphonia. 

B.  Utterance  is  suddenly  arrested  by  spasm  of  the  lips, 
tongue,  glottis  or  respiratory  muscles,  causing  some  of 
the  muscular  contractions  of  normal  speech,  particularly 
those  which  momentarily  stop  the  flow  of  expired  air, 
to  be  unduly  intensified  and  prolonged.  The  difficulty 
is  not  in  making  any  of  the  elementary  sounds  taken 
separately,  but  in  relaxing  the  muscles  needed  for  one 
sound  in  time  to  produce  the  next.  Singing  may  be 
normal.  Always  worse  when  the  patient  feels  himself 
to  be  under  observation. 

Stuttering  (Anarthria  Spasmodica).  Generally  a 
functioJial  neurosis.,  but  may  coniplicate  organic 
brain  disease. 

C.  Certain  literal  sounds  are  formed  with  difficulty  or  not 
at  all,  or  are  misplaced,  so  that  words  are  slurred,  dis- 
torted or  mutilated. 

Sta7n7nering  (Anarthria  Literalis). 
I.   The  defect  is  due  to  paralysis  of  two  or  more  of  the 


DISORDERS    OF    SPEECH. 


-99 


following   organs  :    lips,  tongue,  palate,  pharynx  and 
larynx. 

Bulbai'  or  Psetido-bulbar  Paralysis,  xvhich  see. 

2.  The  impairment  of  utterance  appears  along  with 
hemiplegia  and  is  often  accompanied  for  a  time  by 
some  degree  of  motor  aphasia,  especially  in  right 
hemiplegia. 

Diagnosis  as  i7t  Hetniplegia,  commonly  a  vascular 
lesio7t  in  the  region  of  the  internal  capsule. 

3.  The  defect  in  speech  is  accompanied  by  gradual  im- 
pairment of  judgment  and  memory,  often  by  mon- 
strous and  unsystematized  delusions  of  grandeur.  It 
consists  mainly  of  syllable-stumbling,  especially  over 
words  containing  1  and  r.  A  facial  twitch  often 
accompanies  the  effort  to  speak.  Pupillary  changes 
and  other  signs  of  degenerative  cerebral  disease  are 
common.  Paretic  Dementia. 

4.  The  defect  in  speech  appears  along  with  intention 
tremor,  which  is  often  accompanied  by  nystagmus, 
amblyopia,  various  paralyses  or  other  signs  of  scat- 
tered lesions.  At  first  speech  is  abnormally  distinct 
and  slow  in  a  monotonous  voice,  suggesting  a  school- 
boy's scanning  of  Latin  verse,  but  later  words  are 
slurred  and  indistinct.  Disseminated  Sclerosis. 

5.  There  is  no  evidence  of  organic  nervous  disease. 

a.  The  mode  of  onset  and  accompanying  symptoms 
indicate  hysteria.  The  stammering  varies  greatly 
in  character  and  may  be  combined  with  stuttering. 

Hysterical  Stammering. 

b.  The  defect  is  due  to  the  incoordination  of  the 
vocal  organs  in  chorea.  May  pass  temporarily 
into  complete  motor  aphasia. 

Choreic  Stam?nering. 

c.  The  stammering  is  due  to  a  toxic  state  as  in 
typhoid  fever,  uremia,  gout,  diabetes,  narcotic 
poisoning  or  snake  bite. 

Toxem.ic  Stamm.eri?ig. 


200  NERVOUS    AND    MENTAL    DISEASES. 

II.  The  patient's  vocabulary,  in  at  least  one  of  the  ways  in 
which  language  may  be  used  (speaking,  understanding, 
reading  or  writing),  is  greatly  diminished  and  the  words 
used  in  speaking,  writing  or  reading  aloud  are  often  badly 
arranged.  Aphasia. 

A.  Organic  intracranial  disease  is  indicated  by  the  accom- 
panying symptoms,  particularl}'  paralysis  of  the  face,  a 
sudden  onset  with  disturbance  of  consciousness  (the 
causes  of  a  vascular  lesion  being  present),  hemianopia, 
Jacksonian  epilepsy  or  optic  neuritis.  The  form  of  the 
aphasia  indicates  the  seat  of  the  lesion,  which  is  in  the 
left  hemisphere  in  the  right-handed  and  vice  versa  ;  the 
nature  of  the  disease  is  to  be  inferred  as  in  hemiplegia, 
since  any  organic  change  in  a  cerebral  hemisphere  may 
be  a  cause  of  hemiplegia  or  of  any  form  of  aphasia. 
Softening  from  vascular  occlusion  is  the  most  common 
cause  of  aphasia  because  it  is  the  most  common  change 
in  the  cortex. 
I.   Speech  is  heard  and  understood. 

a.  The  words  spoken  are  very  few  or  perhaps  none 
at  all,  although  the  vocal  organs  are  not  paralyzed. 
Those  that  can  be  spoken  may  be  used  on  all  oc- 
casions without  regard  to  their  meaning,  but  the 
patient  knows  when  he  has  used  them  incorrectly. 
Oaths  and  songs  may  be  retained  without  the 
power  to  use  any  of  the  ^vords  separately. 

Motor  Aphasia. 
i.  Writing  abolished  and  the  comprehension  of 
written  or  printed  language  greatly  impaired 
after  all  indirect  .effects  of  the  lesion  have 
passed  away.  Disability  usually  perma- 
nent. 

Cortical  Motor  Aphasia.     Lesion  of  the 

cortex  at  the  foot  of  the  third  frontal 

convolution. 

ii.   Writing  and  quiet  reading  are  regained  when 

the  indirect  effects  of  the  lesion  have  passed 


DISORDERS    OF    SPEECH.  20I 

away.      The    aphasia    usually    accompanies 
right  hemiplegia,  due  to   a  lesion  of   the   in- 
ternal capsule  and  often  improves  rapidly. 
Stibcortical  Motor    Aphasia.     Lesion   of 
the    xvhite    matter    beneath    the    third 
frontal  convolution. 

b.  The  number  of  words  correctly  spoken  is  large, 
but  the  patient  may  be  unable  to  name  objects 
seen  and  nouns  may  be  lacking  in  spontaneous 
speech.  The  characteristic  symptom  is  the  in- 
ability to  read  aloud  or  to  understand  written  or 
printed  words,  although  they  are  seen  (word- 
blindness).  There  is  always  some  defect  in  the 
right  half  of  each  visual  field  (left  half  in  left- 
handed  persons),  usually  hemianopia,  but  acuity 
of  vision  is  not  sufficiently  impaired  to  ac- 
count for  the  alexia.  Mind-blindness  (the  in- 
ability to  recognize  familiar  objects  when  seen) 
may  be  added  to  the  word-blindness,  indicating 
a  lesion  in   each   hemisphere. 

Visual  Aphasia. 
i.   Writing  is  abolished,  owing  to  the  inability  to 
recall  the  appearance  of  written  words. 

Cortical  Visual  Aphasia.      Lesion  of  the 
angular  gyrus. 
ii.   Spontaneous  writing  is  retained,  although  copy- 
ing is  impaired  or  lost,  but  the  patient  cannot 
read  what  he  has  written. 

Subcortical  Visual  Aphasia.  Lesion  be- 
neath the  angular  gyrus  so  placed  as  to 
interrupt  its  communication  with  the 
right  visual  centers. 

c.  Speaking  and  reading  are  normal,  but  there  is  in- 
ability to  write  with  the  right  hand,  owing  to  in- 
coordination without  paralysis,  while  writing  with 
the  left  hand  is  retained.  Rare.  To  be  carefully 
distinguished    from    the    agraphia     complicating 


17 


202  NERVOUS    AND    MENTAL    DISEASES. 

motor,  visual  or  auditory  aphasia,  which  is  much 
'  more  common. 

Gi'aphomotor  Aphasia.  Probably  a  lesion 
of  the  foot  of  the  second  frontal  convolu- 
tion. 
2.  Speech  is  heard  but  not  understood,  the  words  of  the 
patient's  mother  tongue  sounding  to  him  like  those  of 
an  unknown  language  (word-deafness).  There  is 
also  more  or  less  inability  to  recall  words,  especially 
nouns,  although  the  corresponding  ideas  are  distinct 
(verbal  amnesia).  The  word-deafness  and  verbal 
amnesia  sometimes  exist  alone  but  in  a  typical  case, 
while  some  words  are  correctly  spoken,  w^rong  words 
of  similar  sound  or  meaning  are  often  substituted  for 
the  right  ones  (paraphasia)  and  others  are  mutilated 
so  that  speech  becomes  a  jargon  without  the  patient 
being  aware  of  it.  Writing  suffers  in  the  same  v^ay 
as  speech  (paragraphia)  but  to  a  greater  degree  and 
may  be  entirely  abolished.  Reading  aloud  is  changed 
in  the  same  w^ay  (paralexia)  and  the  comprehension 
of  written  or  printed  words  is  generally  lost. 

Aiiditory  Aphasia.      Lesion  of  posterior  part  of 
frst  temporal  convolution. 
B.   There  is  no  evidence  of  organic  intracranial  disease. 

1 .  Owing  to  deafness  occurring  in  early  life  the  patient 
has  not  learned  to  talk  or  has  forgotten  how. 

Deaf -mutism . 

2.  The  loss  of  words  and  voice  is  generally  absolute, 
yet  the  patient  is  intelligent  and  "writes  readily.  In 
very  rare  cases  writing  may  be  lost  or  recurring  utter- 
ances occur  so  as  to  cause  a  strong  reseinblance  to 
organic  motor  aphasia.  Other  evidence  of  hysteria 
always  present.  Hysterical  Mutism. 

3.  The  aphasia  takes  one  or  more  of  the  forms  described 
as  due  to  organic  disease,  most  commonly  motor 
aphasia  or  a  mild  degree  of  auditory  aphasia. 

a.   There  is  motor  aphasia  following  the  stammering 


DISORDERS    OF    SPEECH.  203 

of  severe  chorea.      Disappears  as  the  chorea  im- 
proves. Choreic  Aphasia. 

b.  The  aphasia  is  one  of  the  phenomena  of  epilepsy 
or  migraine,  lasting  from  a  fev\^  ininutes  to  a  few 
hours.  Epileptic  or  Migrainous  Aphasia. 

c.  The  aphasia  appears  in  the  state  of  profound  ex- 
haustion toward  the  end  of  an  infectious  fever, 
especially  typhoid,  but  disappears  as  strength  re- 
turns. Aphasia  of  Infectious  Fever. 

d.  The  aphasia  is  due  to  a  toxic  state  of  the  blood, 
most  frequently  uremia  or  narcotic  poisoning,  oc- 
casionally diabetes,  gout  or  snake-bite. 

Toxetnic  Aphasia. 


204  NERVOUS    AND    MENTAL    DISEASES. 


INSANITY. 

The  patient's  mind  is  so  undeveloped  or  so  changed  from 
its  normal  condition  as  to  unfit  him  for  the  domestic,  social 
or  business  relations  appropriate  to  his  age  and  station. 
The  delirium  and  stupor  of  acute  fevers  and  acute  intoxi- 
cations are  not  included,  unless  unusually  prolonged. 

I.  The  mental  defect  is  due  to  arrested  development  of  the  mind 
caused  by  disease  or  injury  of  the  brain  in  early  life.  All 
the  later  acquired  powers,  such  as  sustained  attention,  ab- 
stract reasoning,  self-control  and  observance  of  the  social 
proprieties,  are  strikingly  defective  and  in  all  but  the 
slightest  cases  it  is  easy  to  show  a  marked  defect  in  memory. 
Results  or  accompaniments  of  the  cerebral  disease  are  often 
conspicuous,  such  as  cranial  malformation,  hemiplegia, 
monoplegia  or  paraplegia  of  the  spastic  type,  disorders  of 
speech,  epilepsy  and  various  stiginata  of  degeneracy.  A 
history  of  difficult  birth  or  of  convulsions  in  infancy  is  com- 
mon. If  the  arrest  occurs  at  or  before  birth  or  in  early  in- 
fancy and  the  defect  is  very  great,  so  that  the  patient  is 
unable  to  take  proper  care  of  his  person  or  to  express  his 
wants  intelligibly,  it  is  always  called  idiocy  ;  but  if  the  arrest 
occurs  later  or  is  incomplete,  so  that  the  mental  defect  is 
not  so  great,  it  is  often  called  imbecility  or  merely  feeble- 
inindedness,  although  it  is  really  a  milder  degree  of  idiocy. 
Imbeciles  can  generally  care  for  the  person  and  talk  fairly 
well  and  most  of  thein  are  capable  of  considerable  improve- 
ment by  education,  while  a  few  show  exceptional  power  in 
certain  limited  fields,  such  as  music  or  arithmetical  calcula- 
tions. Idiocy. 
On  account  of  its  convenience  for  clinical  purposes  the 
following  classification   of   idiocy   is   taken  from  Frederick 


INSANITY.  205 

Peterson  with  but  slight  modification.      The  same  case  may 
be  in  more  than  one  class. 

A.  The  arrest  of  development  is  caused  by  hydrocephalus. 

Hydrocephalic  Idiocy. 

B.  The  ci^anium  is  abnormally  small. 

Alicrocephalic  Idiocy. 

C.  The  disease  arresting  mental  development  has  caused 
hemiplegia,  paraplegia  or  monoplegia. 

Paralytic  Idiocy. 

D.  The  arrest  of  mental  development  is  due  to  repeated 
epileptic  attacks.  Epileptic  Idiocy. 

E.  The  arrest  is  caused  by  injury  to  the  head. 

Traumatic  Idiocy. 

F.  The  arrest  is  caused  by  meningitis.     Meningitic  Idiocy. 

G.  The  arrest  is  caused  by  scarlatina,  measles,  diphtheria 
or  other  infectious  fever.  Post-febrile  Idiocy. 

H.  Arrest  of  physical  and  mental  development  is  caused  by 
disease  of  the  thyroid  gland  which  is  generally  enlarged. 
The  disease  is  common  in  the  mountainous  regions  of 
Europe  and  Asia,  but  rare  elsewhere.  The  patients  are 
dwarfs  having  the  characteristic  appearance  of  cretins, 
the  skin  being  thick,  coarse  and  yellow,  the  hair  scanty, 
eyelids  puffy,  eyes  small,  nose  flat,  lips  thick,  tongue 
large,  teeth  deficient  and  limbs  deformed.  The  admin- 
istration of  thyroids  causes  improvement  which,  in  some 
cases,  is  very  great.  Myxedematous  Idiocy . 

I.  Degeneration  of  the  retinal  neurons,  causing  blindness, 
and  degeneration  of  the  neurons  of  the  cortex  and  cen- 
tral nervous  system  generally,  causing  idiocy,  occur 
together  in  young  infants  of  certain  families. 

Amaurotic  Idiocy. 

J.  The  patients  show  a  special  aptitude  in  some  limited 
field,  such  as  music,  arithmetical  calculations,  drawing 
or  buffoonery,  which  is  far  in  excess  of  their  other 
powers  and  may  greatly  exceed  that  of  the  average 
normal  individual.  Idiots  Savants. 

K.   The  lack  of  mental  development  is  due  to  deprivation  of 


2o6  NERVOUS    AND    MENTAL    DISEASES. 

sight  and  hearing  and  may  be  remedied  by   appropriate 

education  as  in  the  cases  of  Laura  Bridgman  and  Helen 

Kellar.  Sensorial  Idiocy. 

II.   The  disease  occurs  in  a  mind  ah"eady  developed  and  consists 

in  either  a  perversion  or  a  loss  of  faculties. 

A.  There  is  a  state  of  emotional  exaltation  or  depression, 
accompanied  by  a  corresponding  acceleration  or  re- 
pression of  ideation,  speech  and  action.  There  is  no 
real  failure  of  memory,  although  it  may  be  impossible 
to  secure  the  patient's  attention  sufficiently  to  test  it. 
Delusions,  if  present,  are  secondary  to  the  emotional 
change  and  in  harmony  with  it  and  are  not  systematized. 
There  are  no  signs  of  organic  disease. 

1 .  After  an  initial  stage  of  mental  depression  the  patient 
becomes  excited  and  exhilarated.  His  talk  is  rapid 
and  shows  a  ready,  though  superficial,  association  of 
ideas.  There  is  an  excessive  tendency  to  act  in  accor- 
dance with  any  idea  that  may  occur  and  all  the  ordinary 
restraints  on  speech  and  action  are  absent  or  are  ef- 
fectual for  a  few^  moments  only.  Appetite  and  the 
animal  instincts  generally  are  excessive.  Delusions, 
if  they  occur,  are  of  a  pleasant,  often  of  an  ambitious 
nature  and  are  inconstant  and  often  incoherent.  In 
general,  the  patient  appears  as  though  in  the  excited 
stage  of  alcoholic  intoxication.  All  gradations  exist 
from  the  slightest  noticeable  exhilaration  to  furious 
madness,  marked  by  incoherent  raving  and  blind 
destructiveness.  Mania. 

2.  The  patient  gradually  passes  into  a  state  of  mental 
depression,  in  which  the  association  of  ideas  is  re- 
tarded. Delusions  or  hallucinations,  if  they  occur, 
are  painful  and  include  the  idea  of  personal  disrepute 
or  guilt.  As  a  general  rule  food  is  refused  and 
speech  and  action  repressed  or  almost  abolished,  the 
patient  staring  ahead  in  profound  dejection,  perhaps 
automatically  performing  some  destructive  action 
such  as  picking  clothing  to  pieces.     Exceptionally 


INSANITY.  207 

there  are  frantic  efforts  to  escape  from  imaginary 
evils  (melancholia  agitata).  The  tendency  to  suicide 
is  strong  and  attempts  at  suicide  may  be  preceded  by 
homicide,  under  the  delusion  that  the  victim  is  bene- 
fited by  being  removed  from  a  wretched  world. 

Melancholia. 
3.   Attacks  of  mania  and  melancholia  alternate  with  each 
other,  with   or  without   a   normal    interval,  so  as  to 
form  a  regularly  recurring  cycle.      Incurable. 

Circular  Insanity. 
B.  The  patient  is  subject  to  delusions  which  are  logically 
coherent  or  systematized  and  are  mainly  limited  to  one 
subject.  There  is  no  such  profound  emotional  change 
as  in  mania  or  melancholia  and  memory  is  not  impaired, 
being  exceptionally  accurate  for  occurrences  associated 
with  the  delusions.  There  is  an  hereditary  predisposi- 
tion to  insanity  and  stigmata  of  degeneracy  are  common. 
In  a  typical  case,  after  a  period  of  morbid  introspec- 
tion, there  gradually  develops  a  delusion  of  persecution, 
based  partly  on  hallucinations,  especially  of  cutaneous 
sensibility  and  hearing,  and  partly  on  misinterpretation 
of  actual  occurrences.  The  means  believed  to  be  em- 
ployed by  the  persecutors  varies  with  the  environment, 
education  and  imaginative  power  of  the  patient ;  elec- 
tricity, hypnotism,  mind-reading  and  X-rays  being  com- 
mon now,  while  M^itchcraft  and  demoniac  possession 
were  the  common  means  a  couple  of  centuries  ago.  The 
imaginary  persecution  becomes  more  persistent  and 
systematic  and  is  usually  supposed  to  be  carried  on  by 
some  powerful  organization,  such  as  the  Free-masons, 
the  Catholic  Church  or  a  political  party.  Later,  ap- 
parently as  an  explanation  of  the  persecution,  there  gen- 
erally appears  a  delusion  of  great  personal  importance, 
such  as  being  the  heir  to  a  throne,  a  political  or  religious 
reformer,  a  great  inventor  or  even  Jesus  Christ. 

The  delusions  may  vary  from  the  typical  form  (para- 
noia  querulans,   paranoia   erotica,   paranoia   hypochon- 


208  NERVOUS    AND    MENTAL    DISEASES. 

driaca,  etc.),  and  hallucinations  may  be  especially  prom- 
inent (paranoia  hallucinatoria),  while  in  many  cases  the 
disease  is  but  partially  developed  (cranks),  but  systema- 
tization  is  characteristic  of  all  cases.  The  patient  can 
give  elaborate  reasons  for  his  beliefs,  hovs^ever  absurd, 
and  can  exercise  his  mental  faculties  normally  on  sub- 
jects not  connected  with  the  delusions.  Formerly  called 
monomania.  Incurable.  Some  cases  end  in  a  mild  de- 
mentia. Paranoia. 
C.  There  is  an  intellectual  loss  shown  most  readily  by  a 
failure  of  memory  for  recent  events,  but  always  involv- 
ing impairment  of  the  judgment,  attention,  abstract  rea- 
soning and  esthetic,  social  and  ethical  feeling.  Emo- 
tional changes,  hallucinations  and  delusions  may  occur,  but 
they  are  secondary  and  delusions  are  never  systematized. 

1 .  There  has  been  no  preexisting  mental  disease  or  epi- 
lepsy and  there  is  no  evidence  of  organic  cerebral 
disease.  The  patient,  a  youth  or  young  adult  with 
an  hereditary  predisposition  to  insanity  and  perhaps 
given  to  masturbation,  rapidly  becomes  depressed, 
stupid  and  apathetic,  often  reaching  an  extreme  de- 
gree of  degradation.  As  a  rule  recovery  takes  place, 
leaving  no  recollection  of  the  period  of  stupor,  but 
death  may  occur  or  true  dementia  supervene.  Most 
nearly  related  to  melancholia,  from  which  it  is  dis- 
tinguished by  greater  impairment  of  consciousness 
and  memory  and  absence  of  the  profound  depression 
with  sense  of  guilt  and  of  delusions.  Originally 
called  acute  dementia,  but  differs  from  true  dementia 
in  the  absence  of  organic  cerebral  disease  and  the 
possibility  of  recovery.  Stuporous  Insanity. 

2.  The  mental  defect  is  caused  by  some  form  of  organic 
cerebral  disease  and  is  permanent.  Dementia. 
a.   There  is  coarse  organic  disease  of  the  brain,  such 

as  tumor,  abscess  or  a  vascular  lesion. 

Deme7itia  of  Coarse  Organic  Disease.    Special 
diag?tosis  as  in  Hemiplegia. 


INSANITY.  209 

b.  The  dementia  is  preceded  by  mania  or  melancholia 
or,  i"arely,  by  paranoia  and  at  first  is  mixed  with 
the  exaltation,  depression,  or  delusions  character- 
istic of  the  cause.  Later  these  vestiges  of  the 
original  disease  vanish  and  the  dementia  may  reach 
an  extreme  degree  of  mental  degradation. 

Terminal  Dementia. 

c.  The  faculties  are  lost  as  age  advances.  Differs 
from  the  normal  loss  of  mental  vigor  in  old  age 
only  in  degree.  Senile  Dementia. 

d.  The  dementia  is  preceded  by  prolonged  excess  in 
the  use  of  alcohol,  often  by  attacks  of  delirium 
tremens  and  by  delusions  of  suspicion  and  fear, 
based  on  mental  depression  and  hallucinations, 
somewhat  resembling  the  delusion  of  paranoia,  but 
less  systematized.  Onset  may  be  very  gradual  or 
rapid  during  an  attack  of  delirium  tremens. 

Alcoholic  Dementia. 

e.  The  dementia  gradually  supei'venes  in  epilepsy. 
No  other  cause.  Epileptic  Dementia. 

f.  The  patient  is  almost  always  a  man,  in  early  or 
middle  adult  life,  who  has  been  syphilitic  or  al- 
coholic or  who  is  nervously  exhausted  by  a  fast 
life  or  some  prolonged  strain.  After  a  neuras- 
thenic stage  there  is  a  gradual  alteration  of  char- 
acter and  loss  of  mental  power.  Along  with  the 
mental  defects  common  to  all  forms  of  dementia 
there  are  various  signs  of  degenerative  cerebral  or 
cerebro-spinal  disease.  Speech  is  marred  by 
stumbling  and  perhaps  stuttering,  especially  in 
words  containing  1  and  r.  The  effort  to  speak  or 
to  protrude  the  tongue  is  often  accompanied  by  a 
facial  twitch.  The  writing  is  badly  formed  and 
more  or  less  incoherent  on  account  of  repetitions 
and  omissions.  Tremor  of  the  hands  and  a  fine 
fibrillary  tremor  of  the  tongue  and  lips  are  com- 
mon.     The  pupils  are  generally  unequal  but  the 

18 


2IO  NERVOUS    AND    MENTAL    DISEASES. 

difference  is  inconstant.  Argyll-Robertson  pupil 
may  be  found.  Weakness  or  incoordination  of 
any  or  all  of  the  limbs  may  supervene  and  the 
knee-jerks,  although  usually  exaggerated,  may  be 
lost,  so  as  to  cause  a  strong  resemblance  to  tabes. 
Epileptiform  and  apoplectiform  attacks  are  com- 
mon. In  most,  but  not  all  cases,  the  neurasthenic 
depression  is  succeeded  by  a  stage  in  which  there 
are  monstrous,  unsystematized  delusions  of  wealth, 
power  or  personal  excellence.  Remissions,  even 
apparent  cures,  may  occur,  but  the  disease  always 
advances  again  and  ends  fatally,  generally  within 
two  or  three  years  from  the  onset  of  symptoms. 

Paretic  Dementia. 
D.  The  insanity  presents  a  superficial  resemblance  to  mania 
but  differs  from  it  in  the  more  rapid  onset  and  greater 
violence  of  the  symptoms,  absence  of  the  characteristic 
exhilaration,  greater  impairment  of  consciousness  and 
absence  of  any  subsequent  recollection  of  the  attack. 

1 .  The  patient  is  almost  always  a  man  in  early  or  middle 
adult  life.  There  is  no  prodromal  period  and  the 
onset  is  exceedingly  rapid.  There  is  a  swift  succes- 
sion of  incoherent  ideas,  revealed  by  words,  shouts  or 
inarticulate  cries,  and  accompanied  by  uncontrollable 
rage.  There  is  intense  and  general  motor  excitement 
which  culminates  in  a  blind  destructive  fury.  The 
face  and  conjunctivas  are  flushed,  the  circulation  and 
respiration  accelerated  and  the  temperature  raised. 
The  symptoms  rapidly  subside  within  a  few  hours  to 
a  few  days  of  the  onset,  generally  within  twelve 
hours,  and  end  in  sleep,  from  which  the  patient 
awakes  with  no  recollection  of  the  attack.  Recovery 
is  complete  and  the  attack  does  not  recur.      Rare. 

Transitory  Frenzy. 

2.  The  patient  is  of  neurotic  inheritance,  more  frequently 
a  woman.  The  exciting  cause  may  be  a  fever,  alco- 
holic excess,  puerperal  disease  or  emotional  shock. 


INSANITY.  211 

After  a  prodromal  period  of  not  more  than  a  fe^v 
days  which  is  marked  by  depression,  headache, 
insomnia  and  irritability,  a  violent  delirium  sets  in, 
Under  the  influence  of  constantly  changing,  inco- 
herent hallucinations  and  delusions  the  patient  sings, 
shouts  or  swears  and,  if  unrestrained,  attacks  atten- 
dants and  smashes  furniture.  Anger  or  dread  usually 
predominate  ;  exaltation  is  rare.  Pulse  and  respira- 
tion are  rapid  and  feeble  and  temperature  irregularly 
elevated.  Food  is  generally  refused.  Involuntary 
evacuations  occur.  Ends  within  a  few  weeks,  some- 
times within  a  few  davs,  in  extreme  prostration,  which 
is  followed  by  coma  and  death,  by  dementia,  or  rarelv 
by  recovery  without  recollection  of  the  attack.  Second 
attacks  do  not  occur.  Acute  Delirium. 

E.  The  insanity  is  caused  bv  injury  to  the  brain  or  by  a 
definite  constitutional  condition.  The  mental  syinptoms 
generally  differ  from  the  typical  forms  of  insanitv  in 
being  of  an  incomplete,  mixed  or  inconstant  type  and 
are  better  described  as  delirium  than  as  mania,  melan- 
cholia or  paranoia.  If  maniacal  excitement  occurs  the 
tvpical  exaltation  is  apt  to  be  lacking,  while  unpleasant 
hallucinations,  incoherence  and  confusion  are  more 
prominent  than  in  true  mania.  Although  there  is  often 
a  marked  depression  it  is  not  likely  to  be  so  constant  or 
to  involve  so  great  a  sense  of  guilt  as  in  melancholia. 
Delusions  of  suspicion  or  persecution  frequently  occur 
but  they  are  neither  so  constant  nor  so  coherent  and 
systeinatized  as  in  paranoia.  Temporary  stupor  may 
simulate  dementia  and  genuine  dementia  is  not  an  un- 
common termination. 

I .  Insanity  is  caused  by  a  blow  on  the  head  and  consists 
in  confusion  with  hallucinations  and  delusions  which 
are  generally  of  an  unpleasant  character.  Headache, 
vertigo,  irritability  and  various  physical  defects  are 
common.     May  end  in  recovery  or  in  dementia. 

Tratiinatic  Insanity. 


212  NERVOUS    AND    MENTAL    DISEASES. 

2.  Insanity  is  caused  by  sunstroke,  the  symptoms  being 
like  those  of  traumatic  insanity. 

Insanity  of  Insolation. 

3.  Insanity  resuUs  from  the  excessive  consumption  of 
alcohol,  not  necessarily  causing  drunkenness,  but 
eventually  causing  some  of  the  signs  of  chronic  alco- 
holism, such  as  gastric  catarrh,  cirrhosis  of  the  liver, 
morning  vomiting,  characteristic  odor  of  the  breath, 
bloated  face,  tremor,  etc. 

a.  After  an  unusual  excess  or  on  the  occurrence  of 
some  local  inflammation  or  injury,  or  perhaps 
without  any  exciting  cause,  the  patient  becomes 
dejected,  timid  and  restless.  Sleep  is  at  first  dis- 
turbed by  horrible  dreams  and  within  a  few  days 
these  are  replaced  by  insomnia  with  illusions  and 
hallucinations,  especially  of  seeing  loathsome  and 
dangerous  animals,  accompanied  by  corresponding 
terrifying  dehisions.  For  a  time  the  visions  may 
be  dispelled  and  the  patient  reassured,  but  they 
return  in  constantly  changing  forms  and  he  be- 
comes continuously  delirious,  talking  and  acting 
as  though  at  his  ordinary  work,  reaching  for 
imaginary  objects  or  trying  to  escape  or  to  pro- 
tect himself.  Hallucinations  of  touch,  hearing  or 
smell  may  also  occur.  Speech  becomes  more  and 
more  incoherent  and  may  be  reduced  to  an  unin- 
telligible muttering. 

The  temperature  is  elevated,  the  pulse  rapid  and 
soft  and  there  is  tremor,  especially  of  the  hands, 
face  and  tongue. 

Within  a  ^veek  convalescence  begins  or  there 
is  increasing  prostration  which  generally  leads  to 
coma  and  death.  May  be  complicated  by  pneu- 
monia, hepatic  or  renal  disease,  alcoholic  eclamp- 
sia or  neuritis.  Delirium  Tremens. 

b.  The  mental  symptoms  are  a  complication  of  alco- 
holic multiple  neuritis  and  are  less  acute  than  de- 


INSANITY.  213 

Hrium  tremens,  consisting  mainly  in  loss  of  mem- 
ory for  recent  events  and  a  corresponding  delusion 
of  living  in  the  past.  The  patient  usually  says 
that  he  has  been  out  of  doors,  engaged  in  his  usual 
occupations,  during  the  period  of  illness.  The 
manner  maybe  perfectly  rational.  Recovery  may 
be  complete,  but  there  is  a  tendency  to  dementia. 
Insanity  of  Alcoholic  Neuritis. 

c.  Following  incomplete  recovery  from  delirium  tre- 
mens or  independent  of  it,  there  is  a  gradual 
deterioration  of  character  and  impairment  of  judg- 
ment and  of  memory  for  recent  events.  Hallu- 
cinations, especially  of  hearing,  occur  and  delu- 
sions of  being  the  victim  of  marital  infidelity  or  the 
object  of  a  conspiracy  to  mutilate  or  kill  are  very 
common.  Desperate  attempts  at  escape  or  defense 
may  result  in  serious  injury  to  self  or  in  homicide. 
Differs  from  melancholia  agitata  in  the  prominence 
of  hallucinations  and  in  the  emotional  depression 
being  secondary  and  sense  of  guilt  being  less  pro- 
found ;  -from  paranoia  in  the  inconstancy  of  the 
delusions  and  their  lack  of  systematization.  Im- 
provement generally  occurs  when  alcohol  is  with- 
drawn, but  there  is  a  strong  tendency  toward  in- 
creasing dementia.      Chronic  Alcoholic  Lisajtity. 

d.  The  disease  consists  in  a  periodically  recurring, 
uncontrollable  craving  for  alcoholic  drinks  which 
impels  the  patient  to  degrading  debauches.  During 
the  interval  there  is  no  abnormal  desire  for  drink 
and  conduct  may  be  quite  rational,  but  evidences 
of  a  neurotic  inheritance  and  stigmata  of  degen- 
eration are  common.  Dipsomania. 

(..  The  patient  is  syphilitic.  Beginning,  as  a  rule, 
with  insomnia  and  severe  nocturnal  headache,  he 
passes  into  a  state  of  melancholic  depression  or  ex- 
cited delirium,  often  accompanied  by  delusions  of 
suspicion,  or,  more  frequently,  into  a  dazed,  stupid 


214  NERVOUS    AND    MENTAL    DISEASES. 

condition  resembling  dementia.  The  diagnosis 
may  often  be  confirmed  by  the  presence  or  history 
of  an  eruption,  mucous  patches,  nodes  on  bones,  a 
cerebral  vascular  lesion  in  the  absence  of  atheroma 
or  heart  disease,  or  by  some  other  indication  of 
syphilis ;  it  may,  however,  depend  solely  on  the 
nature  of  the  mental  symptoms  and  the  absence  of 
any  other  adeqviate  cause.  Tends  to  end  in 
dementia,  but  under  appropriate  and  timely  treat- 
ment complete  recovery  may  be  secured. 

Syphilitic  Insanity. 

5.  Insanity  comes  on  durmg  or  soon  after  parturition 
or  during  pregnancy.  The  form  of  the  mental 
symptoms  varies  greatly  in  different  cases  and  is 
often  changeable  in  the  same  case.  Hallucinatory 
delirium  with  confusion  is  the  most  common  condi- 
tion and  \vith  this  there  may  be  depression  simu- 
lating melancholia,  excitement  simulating  mania, 
but  generally  without  exaltation,  and  delusions  of 
suspicion  suggesting  paranoia.  Profound  apathy 
may  occur  and  either  pass  away  or  merge  into  true 
dementia.  Sleep  is  poor  or  absent.  Appetite  is 
generally  poor  and  food  is  often  refused.  The 
duration  may  be  only  a  few  days  or  very  long. 
Many  patients  recover,  but  some  die  and  in 
some  the  insanity  is  permanent. 

Puerperal  Insanity. 

6.  Symptoms  like  those  of  puerperal  insanity  come  on 
after  the  puerperal  period,  owing  to  a  profound 
state  of  exhaustion  which  culminates  during  lacta- 
tion, lactational  Insanity. 

7.  Insanity  occurs  as  a  consequence  of  the  nutritive 
disturbance  of  pulmonary  tuberculosis.  It  is 
marked  by  apathetic  depression  resembling  melan- 
cholia or  dementia,  delusions  of  suspicion  or  a 
confused  hallucinatory  delirium. 

Phthisical  Insanity. 


INSANITY.  215 

8.  The  symptoms  are  like  those  of  phthisical  insanity 
but  are  caused  by  the  cachexia  of  carcinoma. 

Carcinomatous  Insanity. 

9.  In  the  course  of  an  attack  of  articular  rheumatism 
(or  possibly  of  chorea  without  rheumatism)  delirium 
comes  on  and  is  accompanied  by  violent  choreic 
movements.  Delusions  of  suspicion  are  common. 
Signs  of  organic  disease  of  the  central  nervous  sys- 
tem may  appear  and  cardiac  complications  are  com- 
mon.     May  last  w^eeks  or  months. 

Rheumatic  or  Choreic  Insanity. 

10.  Insanity  is  caused  by  an  acute  infectious  disease, 
such  as  typhoid  fever,  pneumonia,  influenza,  scarla- 
tina, septicemia  or  malaria.  It  consists  at  first  in 
confused,  hallucinatory  delirium  vi^hich  may  pass 
into  a  stupor  or  into  delvisions  of  suspicion.  Ends 
mostly  in  recovery,  sometimes  in  idiocy  or  dementia. 

Insanity  of  Infectious  Fever. 

1 1 .  Symptoms  like  those  just  described  are  caused  by 
starvation.  Insanity  of  Inanition. 

12.  Symptoms  like  those  just  described  are  caused  by 
lead,  mercury,  cocaine,  morphine  or  other  poison 
or  by  auto-intoxication  as  in  nephritis  or  diabetes. 

Toxic  Insanity. 

13.  The  patient  is  epileptic  and  the  mental  disturbance 
is  a  part  of  the  epileptic  attacks  or  a  result  of  their 
frequent  occurrence.  To  be  distinguished  f i"om  those 
cases  in  vv^hich  epilepsy  and  insanity  have  a  common 
cause,  as  in  various  forms  of  organic  cerebral  disease, 
a.  The  mental   disturbance  is  transitory,  occurring 

after  the  epileptic  attack  or  just  before  it  or  con- 
stituting the  entire  attack.  It  may  consist  of  an 
hallucinatory  delirium,  leading  sometimes  to  im- 
pulsive acts  of  great  violence,  or  of  a  dazed, 
stupid  condition,  or  perhaps  of  a  condition  ap- 
pearing normal  to  the  casual  observer,  in  vs^hich 
the  patient  performs  accustomed  actions   in   the 


2l6  NERVOUS    AND    MENTAL    DISEASES. 

ordinary  way,  but  is  liable  to  be  impelled  to  any 
foolish  or  criminal  act  by  ideas  over  which  he 
has  no  control.  The  insane  state  may  last  but  a 
few  minutes  or  for  days.  When  it  passes  away 
the  patient  usually  has  absolutely  no  recollection 
of  it  and  at  best  his  recollection  of  it  is  very  im- 
perfect. Transitory  Epileptic  Insanity. 
b.  Owing  to  incomplete  recovery  in  the  intervals, 
the  insane  state,  which  was  at  first  limited  to  the 
time  of  attack,  becomes  nearly  constant  and  ends 
in  epileptic  dementia. 

Chronic  Epileptic  Insanity. 
14.  The  patient  is  subject  to  severe  hysteria  and  the 
mental  symptoms  of  hysteria  merge  into  a  delirium 
which  is  changeable,  highly  emotional  and  marked 
by  profound  egoism  and  a  desire  to  attract  attention. 
Illusions  are  frequent,  hallucinations  also  occur  and 
there  may  be  erotic  or  persecutory  delusions.  To 
be  distinguished  from  other  forms  of  insanity  not 
caused  by  hysteria  but  occurring  in  the  hysterical. 

Hysterical  Insanity. 
i5'  The  patient  is  neurasthenic  and  the  morbid  im- 
pulses, fears,  imperative  ideas,  hypochondriacal 
fancies,  indecision  or  inability  to  fix  the  attention, 
which  are  characteristic  of  neurasthenia,  have 
gradually  become  so  intensified  and  so  dominate 
conduct  as  to  constitute  true  insanity.  The  exal- 
tation of  mania,  the  characteristic  depression  of 
melancholia,  the  systematized  delusions  of  paranoia 
and  the  intellectual  defect  of  dementia  are  entirely 
absent.  The  patient  is  aware  of  the  irrational  action 
of  his  mind  and  deplores  it.  Rare ;  very  many 
neurasthenics  fear  insanity  for  every  one  who  actu- 
ally becomes  insane.  Neurasthenic  Insanity. 
16.  The  patient  has  myxedema  and  the  mind  becomes 
dull,  tending  toward  stupor  and  dementia.  A  con- 
fused   delirium  with    hallucinations    and    changing 


INSANITY.  217 

delusions  may  occur  and  may  be  of  either  the  melan- 
cholic or  the  maniacal  type.  On  the  administration 
of  thyroids  all  symptoms  improve,  at  least  for  a 
time.  Insanity  of  j\Iyxcdc?na. 

17.  The  mental  disturbance  complicates  exophthalmic 
goitre  and  may  be  of  the  melancholic,  maniacal  or 
hysterical  type.     Insaiiity  of  Exophthahnic  Goitre. 


INDEX. 


ABSCESS,    intracranial,    92,    113, 
■^     114,  136,  163,  176 
Accommodation,  spasm  of,  152 
Achilles  reflex,  43 
Acromegaly,  169 
Adiposis  dolorosa,  172 
Alcoholism,  178,  213 
Anarthria  literalis,  199 

spasmodica,  199 
Anesthesia,  marking  limits  of,  48 

hysterical,  81 
Anemia,  cerebral,  160,  166,  179,  196 
Aneurism,  intracranial,  92,  114,  124, 
163,  176 

spinal,  156,  188 
Aorta,  referred  pain  in  disease  of,  189 
Aphasia,  special  forms  of,  201-204 
Aphonia,  hysterical,  81,  129,  199 
Apoplexy,     see      Hemiplegia      and 

Coma 
Argyll-Robertson  pupil,  55 
Arteriosclerosis,  90,  177,  194 
Arthritis  deformans  of  yertebrse,  188 
Astasia-abasia,  106 
Ataxia,  28 

cerebellar,  29 

diagnosis  of    diseases  causing, 
136 

locomotor,  see  Tabes 

spinal,  28 
Atrophy,  arthritic  muscular,  169 

idiopathic  muscular,    135 

muscular,  peroneal  form,  134 

optic,  description  and  diagnosis 
of  diseases  causing,  165 

pseudo-hypertrophic  muscular, 

135 
spinal  muscular,  117,  129,  133 


"DEDSORES,  170 

-'-'     Birth,  injury  at,  18 

palsy,  89,  104,  112 
Bladder,  referred  pain  in  disease  of, 

189 
Blepharospasm,  153 


Bulbar  paralysis,  diagnosis   of  dis- 
eases causing,  I25 

pAISSON  disease,  loi 

^     Capsule,    internal,    lesion     of, 

94'  95 
Carbolic  acid,  poisoning  hy,  198 
Carcinoma,  causing  insanity,  216 
Caries,  spinal,  loi,  155,  156,  185,  188 
Catalepsy,  145 
Centrum  ovale,  lesion  of,  94 
Cerebritis,  92,  113,  163,  164,  176 
Chloral,  poisoning  by,  198 
Chorea,  97,  142,  143,  160,  161,   200, 

216 
Circular  insanity,  208 
Clavus,  in  hysteria,  82 
Clonus,  ankle,  43 
Coma,  diagnosis  of  diseases  causing, 

197 
Compression,  cerebral,  197 
Concussion,  cerebral,  112,  162,  167, 

194'  197 
Conjugate    deviation    of    head    and 

eyes,  122 
Contracture,  hysterical,  148,  158 
Convulsions,  18 

diagnosis   of  diseases   causing, 

143 
Coprolalia,  151 
Cortex,  lesion  of,  94,  121 
Cranium,  disease  of,  167 
Crisis,  laryngeal,  150 
Croup,  spasmodic,  150 
Crus,  lesion  of,  94,  120 
Cutaneous  nerve-supply,  49-52 

sensibility,  48 
Cyst,  intracranial,  92,  114,  124,  163, 
'176 

rvEAF-MUTISM,  203 

^     Degeneration,  reaction  of,  39 

Delirium,  acute,  212 

search  for  physical  cause,  68 

tremens,  213 

219 


220 


INDEX. 


Dementia,  paretic,  90,  104,  116,  118, 
119,  129,  132,  138,  164,  167,  16S, 
194,  200 

Diabetes,  115,  178,  198 

Diphtheria,  115,  125 

Diplopia,  56 

Dipsomania,  214 

Disseminated  sclerosis,  see  Sclero- 
sis, pisseminated 

Double  hemiplegia,  diagnosis  of 
diseases  causing,  100 

"CAR,  examination  of,  53 
diseases  of,  iSo,  iSi 
Echokinesis,  151 
Echolalia,  151 
Eclampsia,     diagnosis    of    diseases 

causing,  145 
Edema,  angioneurotic,  172,  173 

hj'Sterical,  173 
Electrical  reactions,  30 
Embolism,    cerebral,    90,   136,    162, 

163,  167 
Encephalitis(seealso  Cerebritis ) ,  1 76 
Epididjnnis,  referred  pain  in  disease 

of,  189 
Epilepsy,    143,    144,    177,    196,   19S, 
203,  204,  216 
Jacksonian,  149,  150 
Erythromelalgia,  173,  192 
Examination,  method  of,  17 
Expression,     indicative    of    mental 

condition,  67 
Exhaustion,  18,  21 
Eje,  examination  of,  54 

disease  of,  59,  60,  179,  195 

"CACIAL  paralj'sis,  signs  of,  26 

diagnosis  of  diseases  caus- 
ing,i23 
Fallopian  tube,  referred  pain  in  dis- 
ease of,  189 
Family  history,  17 
Faradic  irritability  of  muscles,  30 
Fears,  morbid,  18 
Fevers,  see  Infections 
Fracture  of  skull,  112 

of  vertebr£E,  100,  1S5 
Frenzy,  transitory,  211 
Friedreich's  disease,  137 

GAIT,   normal    and    patholosrical, 
23-25,  28 
Galvanic  irritability,  38 


Globus,  in  hysteria,  79 

Goitre,  exophthalmic,  117,  119,  141, 

173,  218 

TTABITS  of  patient,  18,  20 
^^     Headache,    diagnosis    of     dis- 
eases causing,  174 
Hearing,  tests  of,  153 
Heart,  pains  caused  by  disease  of, 

183,  189 
Heat-stroke,  198 

Hebephrenia,     see    Stuporous    In- 
sanity, 209 
Heel-jerk,  43,  44 
Hemianopia,  63 
Hemiatrophy,  facial,  170 
Hemiplegia,  crossed,  123 

diagnosis  of  diseases  causing, 89 
double,    diagnosis    of    diseases 
causing,  100 
localization  diagnosis,   109 
localization  diagnosis,  94 
partial,    diagnosis    of    diseases 
causing,  96 
localization  diagnosis,  99 
tests    when    patient    is    uncon- 
scious, 27 
with  paralysis   of    ocular  mus- 
cles, 94,  118 
Hemorrhage,  cerebral,  91,  112,  123, 
136,  167 
into  facial  canal,  123 
into  spinal  cord,  100,  185 
meningeal,  90,  91,  no,  112,  162, 

175  ^ 
spinal  meningeal,  102,  156,  188 
Herpes  zoster,  171 
History,    family  and  personal,    17, 

18 
Hydrocephalus,  in,  162,  167 
Hydrophobia,  148 
Hyperemia,  cerebral,  179,  195 
Hyperostosis  cranii,  170 
Hypertrophic      pulmonary     osteo- 
arthropathy, 169 
Hysteria,    25,    78-83,  98,    119,    129, 
'138,  141,  143,  144,   148,    150,    15  [, 

153,  157,  158,  184,   190,    192,    19^, 
199,  203,  217 

TDIOCY,  205 

-*■     Incoordination,  see  Ataxia 

Indigestion,  178 

Infantile  cerebral  palsy,  89 


INDEX. 


221 


Infections,  acute  specific,    115,    nS 

160,  166,  177,  204,  216 
Insanity,  examination  as  to,  65 

definition     and      diagnosis     of 
special  forms,  205 
Intestine,  referred  pains  caused  b>' 
disease  of,  183,  189 

JACKSONIAN  epilepsy,   149,    150 
Jaw-jerk,  45 
Joints,  disease  of,  156,  157,  170 

KIDNEY,  pains  caused  by  disease 
of,  184,  189 
Knee-jerk,  40-43 


Migraine,   117,    167,    177,    196,    203, 

Mixed  forms  of  disease,  86 
Monoplegia,  diagnosis   of    diseases 
causing,  96 
localization  diagnosis,  99 
Mor van's  disease,  172 
Motor  disorders,  general  test  of,  23 
points,  maps  of,  31-36 
segments,  upper  and  lower,  37, 
38 
Muscles,    electrical    reactions    and 

trophic  conditions  of,  30 
Mj'elitis,  100,  161,  170,  185 
Myotonia,  151 
Myxedema,  171,  218 


T  ABYRINTH,  disease  of,  194,  196 
^     Larvnx,  paralysis  of,  27,    125, 
128 
spasm  of,  150,  151 
Lead,  poisoning  by,  115,  179 
Leontiasis  ossea,  170 
Leucocythemia,  160,  166 
Liver,  cirrhosis  of,  198 

pain  caused  bv  disease  of,  1S3, 
1S9 
Lobules,     paracentral,      lesion      of 

110 
Localization,  principles  of,  74    ■ 

cerebral,  75,  76,  94,  99,  109,  no, 

120,  201-203 
spinal,  105,  107-109 
Locomotor  ataxia,  see  Tabes 
Lungs,   pain  caused  by  disease  of, 
183,  189 


MERVE,  facial,  diagram  of,  121 
■'■''        pneumogastric,  lesion  of,   128 
recurrent  laryngeal,  lesion  of, 

128 
sixth,  lesion  of  nucleus,  121 
Nerve-roots,  relation   to    vertebrae, 

105 
Nerves,  cranial,  nuclei  of,  112 

superior  laryngeal,  lesion  of,  128 
Neuralgia,  167,  174 
Neurasthenia,  81,  119,  184,  190,  196, 

217 
Neuritis,  96,  97,  103,  123,   124,   126, 

130-132,  13S,  159,  171,  174,  214 
Neuroma,  130,  174 
Neurosis,  occupation,   130,  141,  151 
Nose,  disease  of,  causing  vertigo,  195 
referred  pain  in  disease  of,  183 
Nystagmus,  56 


MANIA,  207 

■'■'-'•         transitory,       see        Frenzy, 

transitory,  211 
Masturbation,  20 
Medulla  oblongata,  lesion  of,  no 

nuclei  of,  112 
Megalocephalie,  170 
Melancholia,  207,  208 
Meniere's  disease,  19^,  196 
Meningitis,   cerebral,   91,    113,    114, 
124,  163,  164,  176,  177 
cerebro-spinal,  104 
spinal,  102,  156,  188 
Mental    condition,    examination   as 

to,  65 
Mental  peculiarities,  importance  of, 
21 


nCCUPATION      neurosis,       130, 

Ocular  muscles,  56,  59,  61,  in,  120, 
152 

Onset,  mode  of,  18,  73 

Ophthalmoscope,  use  of,  64 

Opium,  poisoning  by,  198 

Orbit,  disease  within,  120,  1159, 
165 

Organic  disease,  general  diagnosis 
of,  69-73 

Osteo-arthropathy,  hypertrophic 
pulmonar_y,  169 

Ovary,  referred  pain  caused  by  dis- 
ease of,  184,  1S9 

Oviduct,  referred  pain  in  disease  of, 
189 


222 


INDEX. 


PACHYMENINGITIS      externa, 


r 


91 


Pain,  diagnosis  of  nervous  diseases 

causing,  174 
referred     in     visceral    disease, 

188,  1S9 
sense,  tests  of,  48 
Paralysis,  acute  ascending,   102 
Paralysis  agitans,  132,  139,  140,  148 
bulbar,   117,   125-127,   129,  168, 

199 
facial,  26,  27,  123 
infantile  cerebral,  104,  112 
laryngeal,  27,  125,  128 
of  ocular  muscles,  56-58,  iii- 

120 
of    partial    or  irregular  extent, 

diagnosis  of  diseases  causing, 

of  palate,  27,  125 

of  pharynx,  27,  125 

of  tongue,  27,  125 

tests  of,  26,  27 
Paramyoclonus  multiplex,  143 
Paranoia,  67,  208,  209 
Paraplegia,  ataxic,  103,  116,  137 

diagnosis  of    diseases  causing, 
100 

localization      diagnosis,       107, 
no 
Paretic    dementia,    see    Dementia, 

Paretic 
Paroxysms,  nervous,  18 
Petit  mal,  19 

Phenol,  poisoning  by,  198 
Polio-encephalitis,  113,  114 

-mj'elitis,  96,  102,  130 
Pons,  lesion  of,  94,  95,  no 
Posture  sense,  53 
Pott's  disease,  see  Caries,  Spinal 
Prostate  gland,  referred  pain  caused 

by  disease  of,  184,  189 
Pupil,  Ai-gyll-Robertson,  55 
Pupils,  reaction  of,  55 


RAYNAUD'S  disease,  172,  191 
A*-     Reaction  of  degeneration,  39 
Records  of  cases,  17 
Rectum,  referred  pain  in  disease  of, 

189 
Reflexes,  significance  of,  47 

superficial,  45 

tendon,  40 

visceral,  47 


RetrocoUis,  155 
Rheumatism,  190,  216 


CCLERODERMA,  172 
^     Sclerosis,  amyotrophic   lateral, 
103,  117,  129,  133 
disseminated,  90,  103,  116, 
124,    129,   132,   137,    140, 
141,  164,  168,  194 
lateral,  103,  168 
postero-lateral,     103,     116, 

137 
Scotomata,  62,  63 

Segments,  spinal,  sensory  areas  cor- 
responding to,  186,  187 
Sensor}'  loss,  marking  limits  of,  48 
Sexual  disorders  and  excesses,  18-20 
Sixth  nerve,  lesion  of  nucleus,  121 
Smell,  tests  of,  53 

Softening,  chronic  progressive  cere- 
bral, 93 
Spasm,  characters  to  be  noted,  29 
facial,  153 
general,    diagnosis   of   diseases 

causing,  142 
glosso-labial,  hysterical,  154 
habit,  151 

in  joint  disease,  156,  157 
in  spinal  caries,  155,  156 
"localized,  diagnosis  of  diseases 

causing,  149 
of  accommodation,  152 
of  larynx,  150,  151 
of  ocular  muscles,  59,  152 
of  muscles  of  mastication,  152, 

153 
of  tongue,  154 
saltatoric,   151 
Speech,  disorders  of,  199 
examination  as  to,  64 
Spells,  nervous,  18 
Spinal  column,  relation  of  vertebral 
spines,        vertebral      bodies, 
spinal    segments   and   nerve 
roots,  105 
cord,  unilateral  lesion  of,  97 
segments,  relation    to    sensory 
areas,  186,  187 
relation  to  vertebrae,  105 
Stammering,  199,  200 
Stomach,   referred  pain  caused   by 
disease  of,  183,  189 
vertigo  caused  by  disease  of ,  195 
Strychnia,  poisoning  by,  147 


INDEX. 


223 


Stupor,     necessity    of    search    for 

physical  cause,  68 
Stuporous  insanity,  209 
Stuttering,  199 
Suggestibility,  18 
Sjncope,  197 
Syphilis,   18,    19,  90,  115,   ii8,   119, 

126,  177,  215 
Syringomyelia,   117,    133,   170,   172, 

191 


Tremor,  characters  to  be  noted,  29 
diagnosis    of  diseases  causing, 

139 
Trismus,  153 

Trophic  condition  of  muscles,  30 
symptoms,    diagnosis    of    dis- 
eases causing,  169 
Tumor,  intracranial,  76,92,  114,124, 
126,  137,  163,  168,  176 
spinal,  102,  156,  188 


T^ABES,    116,    118,    119,    124,    129, 
*■      137,  167,  168,  170,  191,  193 
Tables,  explanation  of,  87 
Taste,  tests  of,  53 
Teeth,  referred  pain  in  disease  of, 

179,  180 
Temperature  sense,  tests  of,  48 
Tendon  reflexes,  44,  45 
Testicle,  referred  pain  in  disease  of, 

184,  189 
Tetanus,  147,  153 
Tetany,  147 

Tic,  convulsive,  151,  152 
Thalamus  optic,  lesion  of,  94 
Thomsen's  disease,  151 
Thrombosis,  cerebral,  90,   91,   no, 
112,  136 
of  cavernous  sinus,  113,  175 
of  lateral  sinus,  176,  182 
Torticollis,  154 
Touch,  tests  of,  48 
Toxic  conditions,  20,  115,  118,   160, 

166,  194,  204,  216 


TTLCER,  perforating  in  tabes,  171 
^      Uremia,  23,  89,  160,   178,    19S, 

216 
Ureter,  referred  pain  in  disease  of, 

183,  189 
Uric  acid' diathesis,  18,  20,  178,  194, 

196 
Urine,  examination  of,  23 
Uterus,  referred  pain  in  disease  of, 

189 

yAGINISMUS,  150 
'       Vaso-motor    symptoms,    diag- 
nosis of  diseases  causing,  169 
Vertebrae,  arthritis  deformans  of  ,188 
fracture-dislocation  of,  100,  185 
Vertigo,  diagnosis  of  diseases  caus- 
ing, 193 
Vision,  tests  of,  61,  62 

^irORRY,  a  cause  of   nervous  dis- 
**      ease,  19 
Writer's  cramp,  130,  141,  151 


A  Classified  Catalogue  of 
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SUBJECT    INDEX. 


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SUBJECT.  PAGE 

Alimentary  Canal  (see  Surgery)  ig 

Anatomy 3 

Anesthetics 14 

Autopsies  (see  Pathology) 16 

Bacteriology  (see  Pathology)..  16 

Bandaging  (see  Surgery) 19 

Blood,  Examination  of 16 

Brain  4 

Chemistry.      Physics 4 

Children,  Diseases  of 6 

Climatology 14 

Clinical  Charts 20 

Compends 22,  23 

Consumption  (see  Lungs) ii 

Cyclopedia  of  Medicine 8 

Dentistry 7 

Diabetes  (see  Urin.  Organs)..  21 

Diagnosis 6 

Diagrams  (see  Anatomy) 3 

Dictionaries,  Cyclopedias  8 

Diet  and  Food 14 

Dissectors 3 

Ear 9 

Electricity  9 

Embryology 3 

Emergencies 19 

Eye 9 

Fevers  ., 9 

Food 14 

Gout ic 

Gynecology  21 

Hay  Fever 2c 

Heart ic 

Histology IC 

Hydrotherapy 14 

Hygiene u 

Hypnotism 14 

Insanity 4 

Intestines  (see  Miscellaneous)  14 
Latin,   Medical  (see  Miscella- 
neous and  Pharmacy) 14,  16 

Life  Insurance 14 

Lungs II 

Massage 12 

Materia  Medica 12 

Mechanotherapy  12 

Medical  Jurisprudence 13 


SUBJECT.  PAGE 

Mental  Therapeutics , 4 

Microscopy  13 

MiUc  Analysis  (see  Chemistry)      4 

Miscellaneous 14 

Nervous  Diseases  14 

Nose 20 

Nursing 15 

Obstetrics 16 

Ophthalmology 9   . 

Organotherapy 14 

Osteology  (see  Anatomy) 3 

Pathology 16 

Pharmacy 16 

Physical  Diagnosis 6 

Physical  Training  12 

Physiology  17 

Pneumotherapy 14 

Poisons  (see  loxicology) 13 

Practice  of  Medicine 18 

Prescription  Books 18 

Refraction  (see  Eye) 9 

Rest 14 

Rheumatism  10 

Sanitary  Science 11 

Skin 19 

Spectacles  (see  Eye) g 

Spine  (see  Nervous  Diseases)  14 
Stomach  (see  Miscellaneous).,.  14 

Students'  Compends 22,  23 

Surgery    and    Surgical    Dis- 
eases   ig 

Technological  Books 4 

Temperature  Charts 6 

Therapeutics 12 

Throat  20 

Toxicology 13 

Tumors  (see  Surgery) 19 

U.  S.  Pharmacopoeia 17 

Urinary  Organs 20 

Urine 20 

Venereal  Diseases 21 

Veterinary  Medicine 21 

Visiting  Lists,  Physicians'. 
(Send /or  Special  Circular.) 

Water  Analysis ix 

Women,  Diseases  of. 21 


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In  Sheets,  Unmounted,  $40.00;  Backed  with  Muslin  and  Mounted 
on  Rollers,  $60.00 ;  Ditto,  Spring  Rollers,  in  Handsome  Walnut  Wall 
Map  Case,  $100.00;  Single  Plates — Sheets,  $5.00 ;  Mounted,  $7.50. 
Explanatory  Key,  .50.     Purchaser  must  pay  freight  charges. 

POTTER.  Compend  of  Anatomy,  Including  Visceral  Anatomy. 
6th  Ed.    16  Lith.  Plates  and  117  other  lUus.     .80 ;  Interleaved,  $1.00 

AVILSON.     Anatomy,     nth  Edition.    429  Illus.,  26  Plates.      $5.00 

^VINDLE.    Surface  Anatomy.    Colored  and  other  Illus.        $1.00 


SUBJECT  CATALOGUE. 


BRAIN  AND  INSANITY  (see  also 
Nervous  Diseases). 

BI^ACKBURN.  A  Manual  of  Autopsies.  Designed  for  the  Use 
of  Hospitals  for  the  Insane  and  other  Public  Institutions.  Ten  flill- 
page  Plates  and  other  Illustrations.  ?i-25 

DERCUM.     Mental  Therapeutics,  Rest,  fete.        Nearly  Ready. 

GORDINIER.  TheGrossand  Minute  Anatomy  of  the,  Central 
Nervous  System.     With  full-page  and  other  Illustrations.      g6.oo 

HORSLEY.  The  Brain  and  Spinal  Cord.  The  Structure  and 
Functions  of.     Numerous  Illustrations.  J2.50 

IRELAND.     The  Mental  Affections  of  Children.    2d  Ed.    ^4.00 

LEWIS  (SEVAN).  Mental  Diseases.  A  Text  Book  Having 
Special  Reference  to  the  Pathological  Aspects  of  Insanity.  26  Litho- 
graphic Plates  and  other  Illustrations.    2d  Ed.  ?7-oo 

MANN.  Manual  of  Psychological  Medicine  and  Allied 
Nervous  Diseases.  $3.00 

PERSHING.  Diagnosis  of  Nervous  and  Mental  Disease. 
Illustrated.    Just  Ready.  $t-25 

REGIS.  Mental  Medicine.  Authorized  Translation  by  H.  M. 
Bannister,  m.d.  j2,oo 

SHUTTLEWORTH.     Mentally  Deficient  Children.  ^1.50 

STEARNS.  Mental  Diseases.  With  a  Digest  of  Laws  Relating 
to  Care  of  Insane.     Illustrated.  Cloth,  ^2. 75  ;  Sheep,  $3.25 

TUKE.  Dictionary  of  Psychological  Medicine.  Giving  the 
Definition,  Etymology,  and  Symptoms  of  the  Terms  used  in  Medical 
Psychology,  with  the  Symptoms,  Pathology,  and  Treatment  of  the 
Recognized  Forms  of  Mental  Disorders.     Two  volumes.  $10.00 

WOOD,  H.  C.    Brain  and  Overwork.  .40 


CHEMISTRY  AND  TECHNOLOGY. 

special  Catalogue  0/  Chetnical  Books  sent  free  upon  application. 

ALLEN.     Commercial    Organic   Analysis.     A  Treatise  on  the 

Modes   of  Assaying  the  Various  Organic  Chemicals   and  Products 

Employed   in  the  Arts,  Manufactures,  Medicine,  etc.,  with  concise 

methods  for  the  Detection  of  Impurities,  Adulterations,  etc.     8vo. 

Vol.  I.  Alcohols,  Neutral  Alcoholic  Derivatives,  etc..  Ethers,  Veg- 
etable Acids,  Starch,  Sugars,  etc.     3d  Edition.  ^4.50 

Vol.  II,  Part  I.  Fixed  Oils  and  Fats,  Glycerol,  Explosives,  etc. 
3d  Edition.  fe-5o 

Vol.  II,  Part  II.  Hydrocarbons,  Mineral  Oils,  Lubricants,  Benzenes, 
Naphthalenes  and  Derivatives,  Creosote,  Phenols,  etc.  3d  Ed.  ^3.50 

Vol.  II,  Part  III.  Terpenes,  Essential  Oils,  Resins,  Camphors,  etc. 
3d  Edition.  Preparing . 

Vol.  Ill,  Part  I.  Tannins,  Dyes  and  Coloring  Matters.  3d  Edition. 
Enlarged  and  Rewritten.     Illustrated.  $\-l° 

Vol.  Ill,  Part  II.  The  Amines,  Hydrazines  and  Derivatives, 
Pyridine  Bases.  The  Antipyretics,  etc.  Vegetable  Alkaloids,  Tea, 
CoflFee,  Cocoa,  etc.     8vo.    2d  Edition.  ^4  50 

Vol.  Ill,  Part  III.  Vegetable  Alkaloids,  Non-Basic  Vegetable  Bitter 
Principles.  Animal  Bases,  Animal  Acids,  Cyanogen  Compounds, 
etc.    2d  Edition,  8vo.  j4-5o 

Vol.  IV.     The  Proteids  and  Albuminous  Principles.     2d  Ed.      ^4.50 


Mii^JUiCAL  BOOKS. 


BAILEY  AND  CADY.     Chemical  Analysis.    Just  Ready.   J1.25 
BARTLEY.     Medical    and     Pharmaceutical    Chemistry.      A 

Text-Book  for  Medical,  Dental,  and  Pharmaceutical  Students.   With 
Illustrations,  Glossary,  and  Complete  Index.     5th  Edition.         $3.00 

BARTLEY.  Clinical  Chemistry.  The  Examination  of  Feces, 
Saliva,  Gastric  Juice,  Milk,  and  Urine.  Ji.oo 

BLOXAM.  Chemistry,  Inorganic  and  Organic.  With  Experi- 
ments,    gth  Ed.,  Revised.     281  Engravings.  Prepari-ng. 

CALDWELL.  Elements  of  Qualitative  and  Quantitative 
Chemical  Analysis.     3d  Edition,  Revised.  Ji.oo 

CAMERON.     Oils  and  Varnishes.     With  Illustrations.  ^2.25 

CAMERON.     Soap  and  Candles.     54  Illustrations  J2.00 

CLOWES  AND  COLEMAN.  Quantitative  Analysis.  5th 
Edition.     122  Illustrations.  %Z-h° 

COBLENTZ.  Volumetric  Analysis.  Illustrated  Just  Ready.  %v. it, 

CONGDON.  Laboratory  Instructions  in  Chemistry.  With 
Numerous  Tables  and  56  Ulustriitions.    Just  Ready.  Ji.oo 

GARDNER.  The  Brewer,  Distiller,  and  Wine  Manufac- 
turer.    Illustrated.  Ji-So 

GRAY.  Physics.  Volume  I.  Dynamics  and  Properties  of  Matter. 
350  Illustrations.    Jtist  Ready.  $4.50 

GROVES  AND  THORP.     Chemical  Technology.     The  Appli- 
cation of   Chemistry   to  the   Arts  and   Manufactures. 
Vol.  I.  Fuel  and  Its  Applications.     607  Illustrations  and  4  Plates. 

Cloth,  $5.00;  J4Mor.,g6.so 
Vol.11.    Lighting.      Illustrated.  Cloth,  $4.00;   J^Mor.,j5.5o 

Vol.  III.  Gas  Lighting.  Cloth,  ^3.50  ;  J^  Mor.,  ^4.50 

Vol.  IV.   Electric  Lighting.     Photometry.  In  Press. 

HOLLAND.  The  Urine,  the  Gastric  Contents,  the  Common 
Poisons,  and  the  Milk.  Memoranda,  Chemical  and  Microscopi- 
cal, for  Laboratory  Use.     6th  Ed      Illustrated  and  interleaved,  Ji.oo 

LEFFMANN.  Compend  of  Medical  Chemistry,  Inorganic 
and  Organic.     4th  Edition,  Revised.  .80;  Interleaved,  Ji. 00 

LEFFMANN.      Analysis  of   Milk   and   Milk    Products.     2d 
Edition,  Enlarged.     Illustrated.  $1.25 

LEFFMANN.  Water  Analysis.  For  Sanitary  and  Technic  Pur- 
poses.    Illustrated.     4th  Edition.  J1.25 

LEFFMANN.  Structural  Formulae,  Including  180  Structural 
and  Stereo-Chemical  Formulae.     i2mo.      Interleaved.  $1.00 

LEFFMANN  AND  BEAM.  Select  Methods  in  Food  Analy- 
sis.    Illustrated     Just  Ready.  $2  50 

MUTER.  Practical  and  Analytical  Chemistry.  2d  American 
from  the  Eighth  English  Edition.  Revised  to  meet  the  requirements 
of  American  Students.     56  Illustrations.  Ji.25 

OETTEL.     Exercises  in  Electro-Chemistry.     Illustrated.        .75 

OETTEL.     Electro-Chemical  Experiments.     Illustrated.         .75 

RICHTER.  Inorganic  Chemistry.  5th  American  from  loth  Ger- 
man Edition.  Authorized  translation  by  Edgar  F.  Smith,  m.a., 
PH.D.     89  Illustrations  and  a  Colored  Plate.  J1.75 

RICHTER.  Organic  Chemistry.  3d  American  Edition.  Trans, 
from  the  8th  German  by  Edgar  F.  Smith.  Illustrated.  2  Volumes. 
Vol.    I.    Aliphatic  Series.     621;  Pages.  J3.00 

Vol.  II.    Carbocvclic  Series.     671  Pages.  $3.00 

ROCKWOOD.  Chemical  Analysis  for  Students  of  Medicine, 
Dentistry,  and  Pharmacy.     Illustrated.    Just  Ready.  ^t.50 

SMITH.     Electro-Chemical  Analysis.    2a  Ed.     28  lUus.       81  25 

SMITH  AND  KELLER.  Experiments.  Arranged  for  Students 
in  General  Chemistry.     4th  Edition.     Illustrated.  .60 


SUBJECT  CATALOGUE. 


SUTTON.  Volumetric  Analysis.  A  Systematic  Handbook  for 
the  Quantitative  Estimation  of  Chemical  Substances  by  Measure, 
Applied  to  Liquids,  Solids,  and  Gases.  8th  Edition,  Revised.  112 
Illustrations.  J5.00 

SYMONDS.  Manual  of  Chemistry,  for  Medical  Students. 
2d  Edition.  J2.00 

TRAUBE.     Physico-chemical  Methods.    Translated  by  Hardin. 

97  Illustrations.  J1.50 

THRESH.     Water  and  Water  Supplies.    3d  Edition.  J2.00 

ULZER  AND   FRAENKEL.    Chemical  Technical  Analysis. 

Translated  by  Fleck.     Illustrated.  $1.25 

WOODY,     Essentials    of    Chemistry    and    Urinalysis.      4th 

Edition.     Illustrated.  J1.50 

***  Special  Catalogue  0/  Books  on  Chemistry  free  upon  application. 

CHILDREN. 

CAUTLEY.     Feeding  of  Infants  and  Young  Children  by  Nat- 
ural and  Artificial  Methods.  $2.00 
HALE.     On  the  Management  of  Children.  .50 

HATFIELD.  Compend  of  Diseases  of  Children.  With  a 
Colored  Plate.     2d  Edition.  .80;    Interleaved,  gi. 00 

IRELAND.     The  Mental  Affections  of  Children.    2d  Ed.    $i,.oa 

MEIGS.  Infant  Feeding  and  Milk  Analysis.  The  Examination 
of  Human  and  Cow's  Milk,  Cream,  Condensed  Milk,  etc.,  and 
Directions  as  to  the  Diet  of  Young  Infants.  .50 

POW^ER.  Surgical  Diseases  of  Children  and  their  Treat- 
ment by  Modern  Methods.     Illustrated.  J2.50 

SHUTTLEWORTH.  Mentally  Deficient  Children.  New 
Edition.  J1.50 

STARR.  The  Digestive  Organs  in  Childhood.  The  Diseases  of 
the  Digestive  Organs  in  Infancy  and  Childhood.  3d  Edition,  Rewrit- 
ten and  Enlarged.     Illustrated.     Just  Ready.  ^3.00 

STARR.  Hygiene  of  the  Nursery.  Including  the  General  Regi- 
men and  Feeding  of  Infants  and  Children,  and  the  Domestic  Manage- 
ment of  the  Ordinary  Emergencies  of  Early  Life,  Massage,  etc.  6th 
Edition.     25  Illustrations.  Ji.oo 

SMITH.     Wasting  Diseases  of  Children.     6th  Edition.        ^2.00 

TAYLOR  AND  WELLS.  The  Diseases  of  Children.  2d  Edi- 
tion, Revised  and  Enlarged.     Illustrated.     8vo.    Just  Ready.    ^4.50 

DIAGNOSIS. 

BROWN.     Medical  Diagnosis.     A  Manual  of  Clinical   Methods. 

4th  Edition.     112  Illustrations.  Cloth,  J2. 25 

DA  COSTA.     Clinical  Examination  of  the  Blood.     Illustrated. 

In  Press. 
EMERY.     Bacteriological  Diagnosis.  Jn  Press. 

MEMMINGER.   Diagnosis  by  the  Urine.   2d  Ed.   24  lUus.  $1.00 


MEDICAL  BOOKS. 


PERSHING.  Diagnosis  of  Nervous  and  Mental  Diseases. 
Illustrated.    Just  Ready .  ^i-25 

STEELL.     Physical  Signs  of  Pulmonary  Disease.  gi.25 

TYSON.  Hand-Book  of  Physical  Diagnosis.  For  Students  and 
Physicians.  By  the  Professor  of  Clinical  Aicuicmc  in  the  University 
of  Pennsylvania.  Illus.  4th  Ed..  Improved  and  Enlarged.  With 
Two  Colored  and  55  other  Illustrations.    Just  Ready.  fi-SO 


DENTISTRY. 

special  Catalogue  of  Dental  Books  sent  free  upon  application. 

BARRETT.  Dental  Surgery  for  General  Practitioners  and 
Students  of  Medicine  and  Dentistry.  Extraction  of  Teeth, 
etc.     3d  Edition.     Illustrated.  $1.00 

BROOMELL,  Anatomy  and  Histology  of  the  Human  Mouth 
and  Teeth.     284  Handsome  Illustrations.  $4.50 

FILLEBROWN.      A     Text-Book     of    Operative     Dentistry. 

Written  by  invitation  of  the  National  Association  of  Dental  Facul- 
ties.    Illustrated.  ^2.25 

GORGAS.  Dental  Medicine.  A  Manual  of  Materia  Medica  and 
Therapeutics.    7th  Edition.    Just  Ready.    Cloth,  ^54.00  ;  Sheep,  J5. 00 

GORGAS.  Questions  and  Answers  for  the  Dental  Student. 
Embracing  all  the  subjects  in  the  Curriculum  of  the  Dental  Student. 
Octavo.     Just  Ready.  J6.00 

HARRIS.  Principles  and  Practice  of  Dentistry.  Including 
Anatomy,  Physiology,  Pathology,  Therapeutics,  Dental  Surgery, 
and  Mechanism.  13th  Edition.  Revised  by  F.  J.  S.  Gorgas,  m.d., 
D.D.s.     1250  Illustrations.  Cloth,  56.00;  Leather,  $7.00 

HARRIS.  Dictionary  of  Dentistry.  Including  Definitions  of  Such 
Words  and  Phrases  of  the  Collateral  Sciences  as  Pertain  to  the  Art  and 
Practice  of  Dentistry.  6th  Edition.  Revised  and  Enlarged  by  Fer- 
dinand F.  S.  Gorgas,  m.d.,  d.d.s.         Cloth,  ^5.00  ;  Leather,  J6.00 

HEATH.  Injuries  and  Diseases  of  the  Jaws.  4th  Edition.  187 
Illustrations.  S4.50 

RICHARDSON.  Mechanical  Dentistry.  7th  Edition.  Thor- 
oughly Revised  and  Enlarged  by  Dr.  Geo.  W.  Warren.  6gi  Illus- 
trations. Cloth,  55.00;  Leather,  g6.oo 

SMITH,     Dental  Metallurgy.     Illustrated.  gi.75 

TAFT.     Index  of  Dental  Periodical  Literature.  52.00 

TOMES.     Dental  Anatomy.    Human  and  Comparative.    263  Illus- 
trations.    5th  Edition.  54.00 
TOMES.     Dental  Surgery.     4th  Edition.     289  Illustrations.     54.00 

WARREN.  Compend  of  Dental  Pathology  and  Dental  Medi- 
cine.    With  a  Chapter  on  Emergencies.     3d  Edition.     Illustrated. 

.80;  Interleaved,  51.25 
WARREN.  Dental  Prosthesis  and  Metallurgy.  129  Ills.  51.25 
WHITE.     The  Mouth  and  Teeth.     Illustrated.  .40 


SUBJECT  CATALOGUE. 


DICTIONARIES. 

GOULD.    The  Illustrated   Dictionary  ot  Medicine,  Biology 

and  Allied  Sciences.     Being  an  Exhaustive  Lexicon  of  Medicine 

and  those  Sciences  Collateral  to  it:    Biology  (Zoology  and  Botany), 

Chemistry,   Dentistry,  Parmacology,  Microscopy,  etc.,  with  many 

useful  Tables  and  numerous  fine  Illustrations.     1633  pages.     5th  Ed. 

Sheep  or  Half  Dark  Green  Leather,  |io.oo;   Thumb  Index,  ^11.00 

Half  Russia,  Thumb  Index,  $12.00 

GOULD.    The  Medical  Student's  Dictionary,    nth  Edition. 

Illustrated.     Including  all  the  Words  and  Phrases  Generally  Used 

in  Medicine,  with  their  Proper  Pronunciation  and  Definition,  Based 

on  Recent  Medical  Literature.     With  a  new   Table   of  Eponymic 

Terms  and  Tests   and   Tables   of  the  Bacilli,  Micrococci,  Mineral 

Springs,  etc.,  of  the  Arteries,  Muscles,  Nerves,  Ganglia,  Plexuses ,  etc. 

nth  Edition.     Enlarged  by  over  100  pages  and  illustrated  with  a 

large  number  of  Engravings.     840  pages. 

Half  Green  Morocco,  ^2.50;  Thumb  Index,  ^3  00 

GOULD.  The  Pocket  Pronouncing  Medical  Lexicon.  4th  Edi- 
tion. (30,000  Medical  Words  Pronounced  and  Defined.)  Containing 
all  the  Words,  their  Definition  and  Pronunciation,  that  the  Medical, 
Dental,  or  Pharmaceutical  Student  Generally  Comes  in  Contact 
With;  also  Elaborate  Tables  of  Eponymic  Terms.  Arteries,  Muscles, 
Nerves,  Bacilli,  etc.,  etc.,  a  Dose  List  in  both  English  and  Metric 
Systems,  etc.,  Arranged  in  a  Most  Convenient  Form  for  Reference  and 
Memorizing.  A  new  (Fourth)  Edition,  Revised  and  Enlarged. 
838  pages. 

Full  Limp  Leather,  Gilt  Edges,  ;Ji.oo  ;  Thumb  Index,  J1.25 
120,000  Copies  of  Gould's  Dictionaries  Have  Been  Sold. 

GOULD  AND  PYLE.  Cyclopedia  of  Practical  Medicine  and 
Surgery.  Seventy-two  Special  Contributors.  Illustrated. 
One  Volume.  A  Concise  Reference  Handbook,  Alphabetically 
Arranged,  of  Medicine,  Surgery,  Obstetrics,  Materia  Medica, 
Therapeutics,  and  the  Various  Specialties,  with  Particular  Reference 
to  Diagnosis  and  Treatment.  Compiled  under  the  Editorial  Super- 
vision of  George  M.  Gould,  m.d..  Author  of  "  An  Illustrated 
Dictionary  of  Medicine  "  :  Editor  "  Philadelphia  Medical  Journal," 
etc.;  and  Walter  L.  Pyle,  m.d..  Assistant  Surgeon  Wills  Eye 
Hospital  ;  formerly  Editor  "International  Medical  Magazine,"  etc., 
and  Seventy-two  Special  Contributors.  With  many  Illustratinns. 
Large  Square  8vo,  to  correspond  with  Gould's  "Illustrated  Dic- 
tionary." Just  Ready.  Full  Sheep  or  Half  Dark-Green  Leather,  ^10.00 
With  Thumb  Index,  ;^ii.oo;  Ha'f  Russia,  Thumb  Index,  J12.00  net. 
*#'"  Sample  Pages   and    Illustrations  and    Descriptive   Circulars    of 

Gould's  Dictionaries  and  Cyclopedia  sent  free  upon  application. 

HARRIS.  Dictionary  of  Dentistry.  Including  Definitions  of  Such 
Words  and  Phrases  of  the  Collateral  Sciences  as  Pertain  to  the  Art 
and  Practice  of  Dentistry.  6th  Edition.  Revised  and  Enlarged  by 
Ferdinand  J.  S.  GoRGAS,  M.D.,  D.D.s.   Cloth,  ;^5. 00;  Leather,  $6  00 

LrONGLEY.  Pocket  Medical  Dictionary.  With  an  Appendix, 
containing  Poisons  and  their  Antidotes,  Abbreviations  used  in  Pre- 
scriptions, etc.  Cloth,  .75  ;  Tucks  and  Pocket,  Ji.oo 

MAXWELL.  Termjnologia  Medica  Polyglotta.  By  Dr. 
Theodore  Maxwell,  Assisted  by  Others.  fo-oo 

The  object  of  this  work  is  to  assist  the  medical  men  of  any  nationality 

in   reading   medical  literature  written   in  a  language  not   their  own. 

Each  term  is  usually  given  in  seven  languages,  viz.  :  English,  French, 

German,  Italian,  Spanish,  Russian,  and  Latin. 

TREVES  AND  LANG.    German-English  Medical  Dictionary . 

Half  Russia,  ^3.25 


MEDICAL  BOOKS. 


EAR  (see  also  Throat  and  Nose). 
BURNETT.     Hearing  and  How  to  Keep  It.    Illustrated.  .40 

DALBY.  Diseases  and  Injuries  of  the  Ear.  4th  Edition.  38 
Wood  Engravings  and  8  Colored  Plates.  J2.50 

HOVELL.  Diseases  of  the  Ear  and  Naso-Pharynx.  Includ- 
ing Anatomy  and  Physiology  of  the  Organ,  together  with  the  Treat- 
ment of  the  Affections  of  the  Nose  and  Pharynx  which  Conduce  to 
Aural  Disease.     128  Illustrations.     2d  Edition.    Just  Ready.      ^5.30 

PRITCHARD.  Diseases  of  the  Ear.  3d  Edition,  Enlarged. 
Many  Illustrations  and  Formulae.  $1.50 


ELECTRICITY. 

BIGELOW.  Plain  Talks  on  Medical  Electricity  and  Bat- 
teries. With  a  Therapeutic  Index  and  a  Glossary  43  Illustra- 
tions.    2d  Edition.  $1.00 

HEDLEY.  Therapeutic  Electricity  and  Practical  Muscle 
Testing.     99  Illustrations.  $2.50 

JACOBY.  Electrotherapy.  2  Volumes.  Illustrated.  Including 
Special  Articles  by  Various  Authors.     (Subscription.)  ?4.5o 

JONES.    Medical  Electricity.   3d  Edition.    117  lUus.  ^3.00 


EYE. 

A  Special  Circular  0/  Books  on  the  Eye  sent  free  upon  application . 

DONDERS.  The  Nature  and  Consequences  of  Anomalies  of 
Refraction.     With  Portrait  and  Illustrations.     Half  Morocco,  gi. 25 

PICK.  Diseases  of  the  Eye  and  Ophthalmoscopy.  Trans- 
lated by  A.  B.  Hale,  m.  d.  157  Illustrations,  many  of  which  are  in 
colors,  and  a  glossary.  Cloth,  J4.50  ;  Sheep,  $5.50 

GOULD  AND  PYLE.    Compend  of  Diseases  of  the  Eye  and 

Refraction.  Including  Treatment  and  Operations,  and  a  Section 
on  Local  Therapeutics.  With  Formulae,  Useful  Tables,  a  Glossary, 
and  III  Illus.,  several  of  which  are  in  colors.     2d  Edition,  Revised. 

Cloth,  .80;  Interleaved,  ^i.oo 

GREEFF.     The  Microscopic  Examination  of  the  Eye.    ^1.25 

HARLAN.     Eyesight,  and  How  to  Care  for  It.     Illus.  .40 

HARTRIDGE.  Refraction.  104  Illustrations  and  Test  Types, 
nth  Edition,  Enlarged      Jzist  Ready.  $1.50 

HARTRIDGE.  On  the  Ophthalmoscope.  4th  Edition.  With 
4  Colored  Plates  and  68  Wood-cuts,     ftist  Ready.  J1.50 

HANSELL  AND  REBER.     Muscular  Anomalies  of  the  Eye. 

Illustrated.  ^1.50 

HANSELL  AND  BELL.  Clinical  Ophthalmology.  Colored 
Plate  of  Normal  Fundus  and  120  Illustrations.  Ji.So 


10  SUBJECT  CATALOGUE. 

MORTON.  Refraction  of  the  Eye.  Its  Diagnosis  and  the  Cor- 
rection of  its  Errors.     6th  Edition.  Ji.oo 

OHLEMANN.  Ocular  Therapeutics.  Authorized  Translation, 
and  Edited  by  Dr.  Charles  A.  Oliver.  Ji-75 

PARSONS.     Elementary  Ophthalmic  Optics.  In  Press. 

PHILLIPS.  Spectacles  and  Eyeglasses.  Their  Prescription 
and  Adjustment.     2d  Edition.      49  Illustrations.  $1.00 

SWANZY.     Diseases  of  the  Eye  and  Their  Treatment.    7th 

Edition,  Revised  and  Enlarged.     164   Illustrations,  i  Plain   Plate, 
and  a  Zephyr  Test  Card.  $2.50 

THORINGTON.  Retinoscopy.  4th  Edition.  Carefully  Revised. 
Illustrated.    Just  Ready.  $1.00 

THORINGTON.  Refraction  and  How  to  Refract.  200  Illustra- 
tions, 13  of  which  are  Colored.     2d  Edition.  J1.50 

WALKER.  Students'  Aid  in  Ophthalmology.  Colored  Plate 
and  40  other  Illustrations  and  Glossary.  Ji-So 

WRIGHT.  Ophthalmology.  2d  Edition,  Revised  and  Enlarged. 
117  Illustrations  and  a  Glossary.    Just  Ready.  fooo 

FEVERS. 

GOODALL  AND  WASHBOURN.  Fevers  and  Their  Treat- 
ment.    Illustrated.  $3-oo 

GOUT  AND  RHEUMATISM. 

DUCK\A^ORTH.  A  Treatise  on  Gout.  With  Chromo-lithographs 
and  Engravings.  Cloth,  J6.00 

HAIG.  Causation  of  Disease  by  Uric  Acid.  A  Contribution  to 
the  Pathology  of  High  Arterial  Tension,  Headache,  Epilepsy,  Gout, 
Rheumatism,  Diabetes,  etc.     5th  Edition.  fo  00 

HEART. 

THORNE.  The  Schott  Methods  of  the  Treatment  of  Chronic 
Heart  Disease.     Third  Edition.     Illustrated.  ?i  75 

HISTOLOGY. 

GUSHING.  Compend  of  Histology.  By  H.  H.  Gushing,  m.d  , 
Demonstrator  of  Histology,  Jefferson  Medical  College,  Philadelphia. 
Illustrated.     Nearly  Reaay-.  .80;  Interleaved,  Ji.co 

STIRLING.  Outlines  of  Practical  Histology.  368  Illustrations. 
2d  Edition,  Revised  and  Enlarged.     With  nevt'  Illustrations.       $2.00 

STOHR.  Histology  and  Microscopical  Anatomy.  Edited  by 
A.  ScHAPER,  M.D.,  University  of  Breslau,  formerly  Demonstrator  of 
Histology,  Harvard  Medical  School  Fourth  American  from  9th  Ger- 
man Edition,  Revised  and  Enlarged.     379  lUus.    Just  Ready.    $3.00 


MEDIC A.I,  BOOKS. 


HYGIENE  AND  WATER  ANALYSIS. 

special  Catalogue  of  Books  on  Hygiene  sent  free  upon  application. 

CANFIELD.  Hygiene  of  the  Sick-Room,  A  Book  for  Nurses 
and  Others.  Being  a  Brief  Consideration  of  Asepsis,  Antisepsis,  Dis- 
infection, Bacteriology,  Immunity,  Heating,  Ventilation,  etc.       J1.25 

CONN.     Agricultural  Bacteriology.     Illus.   Just  Ready.      ^2.50 

COPLIN.  Practical  Hygiene.  A  Complete  American  Text-Book. 
138  Illustrations.     New  Edition.  Preparing, 

HARTSHORNE.     Our  Homes.     Illustrated.  .40 

KENWOOD.  Public  Health  Laboratory  'Work.  116  Illustra- 
tions and  3  Plates.  $2.00 

LEFFMANN.  Select  Methods  in  Food  Analysis.  53  Illustra- 
tions and  4  Plates.    Just  Ready.  J2.50 

LEFFMANN.  Examination  of  Water  for  Sanitary  and 
Technical  Purposes.     4th  Edition.     Illustrated.  iJii.zS 

LEFFMANN.  Analysis  of  Milk  and  Milk  Products.  Illus- 
trated.    Second  Edition.  Ji.zs 

LINCOLN.    School  and  Industrial  Hygiene.  .40 

McFARLAND.    Prophylaxis  and  Personal  Hygiene.   In  Press. 

NOTTER.  The  Theory  and  Practice  of  Hygiene.  15  Plates 
and  138  other  Illustrations.     8vo.     2d  Edition.  J7.00 

PARKES.  Hygiene  and  Public  Health.  By  Louis  C.  Parkes, 
M.D.     6th  Edition.     Enlarged.     Illustrated.    Just  Ready.  iSs.oo 

PARKES.  Popular  Hygiene.  The  Elements  of  Health.  A  Book 
for  Lay  Readers.     Illustrated.  $1.25 

STARR.  The  Hygiene  of  the  Nursery.  Including  the  General 
Regimen  and  Feeding  of  Infants  and  Children,  and  the  Domestic 
Management  of  the  Ordinary  Emergencies  of  Early  Life,  Massage, 
etc.     6th  Edition.     25  Illustrations.  Ji.oo 

STEVENSON  AND  MURPHY.  A  Treatise  on  Hygiene.  By 
Various   Authors,     in    Three    Octave   Volumes.     Illustrated. 

Vol.  I,  $6.00;  Vol.  11,^6.00;   Vol.  Ill,  $5.00 
*:it*  Each  Volume  sold  separately.   Special  Circular  upon  application. 

THRESH.     Water  and  Water  Supplies.     3d  Edition.  J2.00 

WILSON.    Hand-Book    of  Hygiene  and   Sanitary    Science. 

Wiih  Illustrations.     8th  Edition.  ?300 

WEYL.  Sanitary  Relations  of  the  Coal-Tar  Colors.  Author- 
ized Translation  by  Henry   LeFPMANN,  M.D. ,  PH.D.  $1.2$ 


LUNGS  AND  PLEUR^ffi. 

KNOPF.      Pulmonary   Tuberculosis.      Its   Modern  Prophylaxis 
and  Treatment  in  Special  Institutions  and  at  Home.     Illus.        S3.00 

STEELL.     Physical  Signs  of  Pulmonary  Disease.   Illus.  $1.25 


SUBJECT   CATALOGUE. 


MASSAGE— PHYSICAL  EXERCISE. 

OSTROM.  Massage  and  the  Original  Swedish  Move- 
ments. Their  Application  to  Various  Diseases  of  the  Body.  A 
Manual  for  Students,  Nurses,  and  Physicians.  Fourth  Edition,  En- 
larged.    105  Illustrations,  many  of  which  are  original.  $1.00 

MITCHELL  AND  GULICK.  Mechanotherapy.  lUus.  In  Press. 
TREVES.     Physical  Education.     Methods,  etc.  .75 

WARD.     Notes  on  Massage.     Interleaved.  Paper  cover,  Ji. 00 


MATERIA    MEDICA    AND     THERA- 
PEUTICS. 

BIDDLE.  Materia  Medica  and  Therapeutics.  Including  Dose 
List,  Dietary  for  the  Sick,  Table  of  Parasites,  and  Memoranda  ot 
New  Remedies.  13th  Edition,  Revised.  64  Illustrations  and  a 
Clinical  Index.  Clotb,  $4.00;  Sheep,  J5.00 

BRACKEN.     Outlines  of  Materia  Medica  and  Pharmacology.    $2.75 

COBLENTZ.  The  Newer  Remedies.  Including  their  Synonyms, 
Sources,  Methods  of  Preparation,  Tests,  Solubilities,  Doses,  etc. 
3d  Edition,  Enlarged  and  Revised.  $1.00 

COHEN.  Physiologic  Therapeutics.  Mechanotherapy,  Mental 
Therapeutics,  Electrotherapy.  Climatology,  Hydrotherapy,  Preu- 
malotheiapj'.  Prophylaxis,  Dietetics,  etc.  11  Volumes.  Octavo. 
Illustrated.     (^Subscription.)  Cloth,  ^27.50  ;  J^  mor.,  138.50 

Special  Descriptive  Circular  -will  be  sent  -upon  application. 
DAVIS.    Materia  Medica  and  Prescription  Writing.        Ji-so 

GORGAS.  Dental  Medicine.  A  Manual  of  Materia  Medica  and 
Therapeutics.     7th  Edition,  Revised,     fuit  Ready.  J4.00 

GROFF.  Materia  Medica  for  Nurses,  with  questions  for  Self  Exam- 
ination and  a  complete  Glossary.  $1.25 

HELLER.  Essentials  of  Materia  Medica,  Pharmacy,  and 
Prescription  'Writing.  iSi-So 

MAYS.     Theine  in  the  Treatment  of  Neuralgia.     %  bound,  .50 

POTTER.  Hand-Book  of  Materia  Medica,  Pharmacy,  and 
Therapeutics,  including  the  Action  of  Medicines,  Special  Therapeu- 
tics, Pharmacology,  etc.,  including  over  600  Prescriptions  and  For- 
mulae 8th  Edition.  Revised  and  Enlarged.  With  Thumb  Index  in 
each  copy     J-ust  Ready.  Cloth.  J5. 00;   Sheep,  J6.C0 

POTTER.  Compend  of  Materia  Medica,  Therapeutics,  and 
Prescription  Writing,  with  Special  Reference  to  the  Physiologi- 
cal Action  of  Drugs.     6th  Edition  .80:    Interleaved,  gi. 00 

MURRAY.     Rough  Notes  on  Remedies.     4th  Edition.  Ji  25 


MEDICAL  BOOKS.  1? 


SATRS.  Organic  Materia  Medica  and  Pharmacognosy.  An 
Introduction  to  the  Study  of  the  Vegetable  Kingdom,  and  the  Vege- 
table and  Amnigl  Drugs.  Comprising  the  Botanical  and  Physical 
Characteristics,  Source,  Constituents,  and  Pharmacopeal  Prepara- 
tions, Insects  Injurious  to  Drugs,  and  Pharmacal  Botany.  With 
sections  on  Histology  and  Microtechnique,  by  W.  C.  Stevens. 
374  Illustrations,  many  of  which  are  original.    2d  Edition. 

Qotli,  J4.3Q 

TAVERA.     Medicinal  Plants  of  the  Philipptnes.    J-j^i  Rnzdy. 

$z.zc 

V^HITE  AND  WILCOX.  Materia  Medica,  Pharmacy,  Phar- 
macology,  and  Therapetitics.  ~tii  .American  Edition,  Revised  by 
Retnold  W.  WrLcox,  m.a.,  m.d,,  ix-d..  Professor  of  Clinical 
Medicrae  and  Therapeutics  at  the  New  York  Post-Gradoare  Medical 
School.    Jusi  Riody.  Cloth,  fe.oo ;  Leather,  J3.30 

"  The  care  with  which  Dr.  WQcoz  has  performed  his  work  is  con- 
spicuous on  every  page,  and  it  is  evident  that  no  recent  drug  possess- 
ing any  merit  has  escaped  his  eye.  We  believe,  on  the  whole,  this  is 
the  best  book  on  Materia  Medica  and  Therapeutics  to  place  in  the 
hands  of  students,  and  the  practitioner  will  find  it  a  most  satisfe-CCsry 
work  for  daily  use." — Tke  CIsoela.nd  Midzcal  G<izette. 


MEDICAL    JURISPRUDENCE     AND 
TOXICOLOGY. 

REESE.    Medical  Jurisprudence  and  Toxicology.  A  Text-Book 

for   Medical   and   Legal   Pracnttoners   and  Students.     5th   Edition. 
Revised  by  Henst  LEBTivrANit,  m.d.       Clo.,  J3.00  ;  Leather,  ^3.50 

"  To  the  student  of  medical  jurisprudence  and  toxicology  it  is  in- 
valuable, as  it  is  concise,  clear,  and  thorough  in  every  respect." — TTu 
Atnerica-n  Ja'A-rnai  oftki  MidicaZ  Scidttcn. 

MANN.     Forensic  Medicine  and  Toxicology.    EEus.  {6-5= 

TANNER.     Memoranda  of  Poisons.    Their  Antidotes  and  Tests. 

8th  Edition,  by- Dh.  Henst  Lsffmamh.    J:ist  RjizSy.  .75 


MICROSCOPY. 

CARPENTER.  The  Microscope  and  Its  Revelations.  3th 
Edition,  Revised  and  Enlarged  Si-  Illustrations  and  33  Plates. 
fust  Riody.  Cloth,  |S.co  ;  Half  Morocco,  ^.cc 

LEE.      The    Microtomist's    Vade    Mecnm.      A   Hand-Book  ai 

Methods  of  Microscopical  Anatomy.     SS7  -\rticles.      5th  Edition. 
Enlarged.  '  '  j4-cc 

REEVES.  Medical  Microscopy,  including  Chapters  on  Bact^i- 
ology.  Neoplasms.  Urinary  Examination,  etc.  Numerous  IHns- 
trauons,  some  ot  which  are  pruited  in  colors.  Js.fc 

WETHERED.  Medical  Microscopy.  A  Guide  to  die  Use  of  the 
Microscope  in  Practical  Medicine,     too  Illustrations.  {2.00 


SUBJECT  CATALOGUE. 


MISCELLANEOUS. 

BERRY.     Diseases  of  Thyroid  Gland.     Illustrated.  J4.00 

BURNETT.     Foods  and  Dietaries.     A  Manual  of  Clinical  Diet- 
etics.    2d  Edition.  $i-5o 
BUXTON.     Anesthetics.    Illustrated.    3d  Edition.                   $1-50 
COHEN.     Organotherapy.                                                      In  Press. 
DAVIS.     Dietotherapy.     Food  in  Health  and  Disease.     [Sub- 
scription.)   Just  Ready.  J2.50 
GOULD.      Borderland    Studies.      Miscellaneous   Addresses   and 
Essays.     i2mo.                                                                                          $2.00 
GREENE.     Medical  Examination  for  Life  Insurance.     Illus- 
trated. $4-oo 
HAIG.     Causation  of  Disease  by  Uric  Acid.     The  Pathology  of 
High  Arterial  Tension,  Headache,  Epilepsy,  Gout,    Rheumatism, 
Diabetes,  Bright's  Disease,  etc.     st^Edition.                                  feoo 
HAIG.     Diet  and  Food.     Considered  in  Relation  to  Strength  and 
Power  of  Endurance.     3d  Edition.    Just  Ready.                           $1.00 
HEMMETER.     Diseases  of  the  Stomach.     Their  Special  Path- 
ology, Diagnosis,  and  Treatment.     With  Sections  on  Anatomy,  Diet- 
etics, Surgery,  etc.    2d  Edition,  Revised  and  Enlarged.     Illustrated. 

Cloth,  g6.oo;  Sheep,  $7.00 
HEMMETER.  Diseases  of  the  Intestines.  Illustrated.  2  Vol- 
umes. 8vo  Just  Ready.  $10  00 
HENRY.  A  Practical  Treatise  on  Anemia.  Hall  Cloth,  .50 
LEFFMANN.  Food  Analysis.  Illustrated.  Just  Ready.  $2.50 
NEW  SYDENHAM  SOCIETY'S  PUBLICATIONS.  Circulars 
upon  application.  Per  Annum,  J8.00 
OSGOOD.  The  'Winter  and  Its  Dangers.  .40 
OSLER  AND  McCRAE.  Cancer  of  the  Stomach.  ^2.00 
PACKARD.  Sea  Air  and  Sea  Bathing.  .40 
RICHARDSON.  Long  Life  and  How  to  Reach  It.  .40 
ST.  CLAIR.  Medical  L-atin.  Ji.oo 
TISSIER.  Pneumatotherapy.  In  Press. 
TURNBULL.  Artificial  Anesthesia,  ^th  Edition.  lUus.  $2.50 
WEBER  AND  HINSDALE.  Climatology.  2  Vols.  lUus'rated 
with  Maps.  Jtist  Ready.  {Subscription.)  ?4  5° 
^VILSON.  The  Summer  and  Its  Diseases.  .40 
■WINTERNITZ.     Hydrotherapy.     Illustrated.                  In  Press. 

NERVOUS  DISEASES. 

DERCUM.    Rest,  Hypnotism,  Mental  Therapeutics.    In  Press. 

GORDINIER.  The  Gross  and  Minute  Anatomy  of  the  Cen- 
tral Nervous  System.  With  271  original  Colored  and  other 
Illustrations.  Cloth,  J6.00;  Sheep,  J7.00 

GOWERS.  Manual  of  Diseases  of  the  Nervous  System.  A 
Complete  Text-Book.  Revised,  Enlarged,  and  in  many  parts  Re- 
written. With  many  new  Illustrations.  Two  volumes. 
Vol.  I.  Diseases  of  the  Nerves  and  Spinal  Cord.  3d  Edition,  En- 
larged. Cloth,  $4.00 ;  Sheep,  $5.00 
Vol.  II.  Diseases  of  the  Brain  and  Cranial  Nerves ;  General  and 
Functional  Disease.     2d  Edition.              Cloth,  $4.00;  Sheep,  J5.00 

GOWERS.    Syphilis  and  the  Nervous  System.  $1.00 


MEDICAL  BOOKS.  15 


GCWERS.   Epilepsy  and  Other  Chronic  Convulsive  Diseases. 

2d  Edition.     Just  Ready.  fo.oo 

HORSLEY.    The   Brain   and  Spinal  Cord.    The  Structure  and 
Functions  of.     Numerous  Illustrations.  ^^-SO 

ORMEROD.     Diseases  of  the  Nervous  System.     66  Wood  En- 
gravings. |i.oo 

OSLER.    Chorea  and  Choreiform  Affections.  $2.00 

PERSHING.      Diagnosis  of  Nervous  and  Mental  Diseases. 

lUustiated.    Just  Ready.  ^1-25 

PRESTON.     Hysteria  and  Certain  Allied  Conditions.     Their 

Nature  and  Treatment.     Illustrated.  ^2.00 

■WOOD.     Brain  Work  and  Overwork.  .40 


NURSING  (see  also  Massage). 

special  Catalogue  of  Books  for  Nurses  sent  free  upon  application. 

CANFIELD.  Hygiene  of  the  Sick-Room,  A  Book  for  Nurses  and 
Others.  Being  a  Brief  Consideration  ot  Asepsis,  Antisepsis,  Disinfec- 
tion, Bacteriology,  Immunity',  Heating  and  Ventilation,  and  Kindred 
Subjects  for  the  Use  of  Nurses  and  Other  Intelligent  Women,     gi.25 

CUFF.     Lectures  to  Nurses  on  Medicine.     Third  Edition.    $1.25 

DOMVILLE.    Manual  for  Nurses  and  Others  Engaged  in  At- 
tending the  Sick,    gth  Edition.   With  Recipes  for  Sick-room  Cook- 
ery, etc.  In  Press. 
FULLERTON.     Obstetric  Nursing.     41  Ills.     5th  Ed.  Ji.oo 
FULLERTON.     Surgical    Nursing.    3d  Ed.    69  Ills.          $1.00 

GROFF.  Materia  Medica  for  Nurses.  With  Questions  for  Self-Ex- 
amination  and  a  very  complete  Glossary.  $1.25 

"  It  will  undoubtedly  prove  a  valuable  aid  to  the  nurse  in  securing  a 

knowledge  of   drugs  and   their   uses.'' — The  Medical  Record,   New 

York. 

HADLEY.     Medical  and  Surgical  Nursing.        Nearly  Ready. 

HUMPHREY.      A    Manual    for     Nurses.      Includmg     General 

Anatomy  and   Physiology,  Management   of  the   Sick   Room,    etc. 

23d  Edition.     79  Illustrations.  Ji.oo 

"  In  the  fullest  sense.  Dr.  Humphrey's  book  is  a  distinct  advance  on 
all  previous  manuals.  It  is,  in  point  of  fact,  a  concise  treatise  on 
medicine  and  surgery  for  the  beginner,  incorporating  with  the  text  the 
management  of  childbed  and  the  hygiene  of  the  sick-room.  Its  value 
is  greatly  enhanced  by  copious  wood-cuts  and  diagrams  of  the  bones 
and  internal  organs." — British  Medical  Jour  nal ,  London. 

STARR.  The  Hygiene  of  the  Nursery.  Including  the  General 
Regimen  and  Feedmg  of  Intants  and  Children,  and  the  Domestic  Man- 
agement of  the  Ordinary  Emergencies  of  Early  Life,  Massage,  etc.  6th 
Edition.     25  Illustrations.  ^i.oo 

TEMPERATURE  AND  CLINICAL  CHARTS.    See  page  6. 

VOSWINKEL.  Surgical  Nursing.  Second  Edition,  Enlarged. 
112  Illustrations.  Ji.oo 


16  SUBJECT  CATALOGUE. 

OBSTETRICS. 

CAZEAUX  AND  TARNIER.  Midwifery.  With  Appendix  by 
MundA.  The  Theory  and  Practice  of  Obstetrics,  including  the  Dis- 
eases ot  Pregnancy  and  Parturition,  Obstetrical  Operations,  etc. 
8th  Edition.  Illustrated  by  Colored  and  other  full-page  Plates,  and 
numerous  Wood  Engravings.  Cloth,  J4.50  ;  Full  Leather,  J5.50 

EDGAR.     Text-Book  of  Obstetrics.     Illustrated.       Preparing. 

FULLERTON.    Obstetric  Nursing.     5th  Ed.    Illustrated.    Ji.oo 

LANDIS.  Compend  of  Obstetrics.  7th  Edition,  Revised  by  Wm. 
H.  Wells,  Demonstrator  oi  Clinical  Obstetrics,  Jefferson  Medical 
College.     52  Illustrations.    Just  Ready.  .80;  Interleaved,  ^1.00 

WINCKEL.  Text-Boolt  of  Obstetrics,  Including  the  Pathol- 
ogy and  Therapeutics  of  the  Puerperal  State.  Authorized 
Translation  by  J.  Clifton  Edgar,  m.d.     IUus.  Cloth,  $5.00 

PATHOLOGY. 

BARLOW.     General  Pathology.     795  pages.     8vo.  $5.00 

BLACK.     Micro-Organisms.     The  Formation  of  Poisons.  .75 

BLACKBURN.  Autopsies.  A  Manual  of  Autopsies  Designed  for 
the  Use  of  Hospitals  for  the  Insane  and  other  Public  Institutions. 
Ten  full-page  Plates  and  other  Illustrations.  $1-25 

CONN.     Agricultural  Bacteriology.     Ilhis.    Just  Ready.      $2.50 
COPLIN.  Manual  of  Pathology.  Including  Bacteriology,  Technic 
of  Post-Mortems,  Mrthods  of  Pathologic  Research,  etc.     33c  Illus- 
trations, 7  Colored  Plate«.     3d   Edition.  ?3-50 

DA  COSTA.  Clinical  Hematology.  Six  Colored  Plates  and  48 
Illustrations,     fust  Ready.  ^5-oo 

EMERY.     Bacteriological  Diagnosis.  In  Press. 

HEWLETT.  Manual  of  Bacteriology.  75  Illustrations.  ^3.00 
ROBERTS.  Gynecological  Pathology.  IUus.  Just  Ready  ^6.00 
THAYER.  Compend  of  General  Pathology.  Illustrated. 
Nearly  Ready.  .80;  Interleaved,  |i.co 
THAYER.     Compend  of  Special  Pathology.     Illustrated. 

Nearly  Ready.     .80  ;   Interleaved,  %i  00 
VIRCHOW.     Post-Mortem  Examinations.     3d  Edition.  .75 

WHITACRE.  Laboratory  Text-Book  of  Pathology.  With 
121  Illustrations.  ^i-5o 

WILLIAMS.  Bacteriology.  A  Manual  for  Students.  90  Illus- 
trations.    2d  Edition,  Revised.    Jtist  Ready.  ^i-So 

PHARMACY. 

special  Catalogue  of  Books  on  Pharmacy  sent  free  upon  application. 

COBLENTZ.  Manual  of  Pharmacy.  A  Complete  Text-Book 
by  the  Professor  in  the  New  York  College  of  Pharmacy.  2d  Edition, 
Revised  and  Enlarged.   437  IUus.  Cloth,  83.50;  Sheep,  84.50 

COBLENTZ.     Volumetric  Analysis.     Illustrated.  In  Press. 

BEASLEY.  Book  ot  3100  Prescriptions.  Collected  from  the 
Practice  of  the  Most  Emment  Physicians  and  Surgeons — English, 
French,  and  American.  A  Compendious  History  oi  the  Materia 
Medica,  Lists  of  the  Doses  of  all  the  Officinal  and  Established  Pre- 
parations, an  Ipdex  of  Diseases  and  their  Remedies.     7th  Ed.    82.00 


MEDICAL   BOOKS. 


BEASLEY.  Druggists'  General  Receipt  Book.  Comprising 
a  Copious  Veterinary  Formulary,  Recipes  in  Patent  and  Proprietary 
Medicines,  Druggists'  Nostrums,  etc. ;  Perfumery  and  Cosmetics, 
Beverages,  Dietetic  Articles  and  Condiments,  Trade  Chemicals, 
Scientific  Processes,  and  many  Useful  Tables.     loth  Ed.  J2.00 

BEASLEY.  Pharmaceutical  Formulary.  A  Synopsis  of  the 
British,  French,  German,  and  United  States  Pharmacopoeias.  Com- 
prising Standard  and  Approved  Formulae  for  the  Preparations  and 
Compounds  Employed  in  Medicine.     12th  Edition.  J2.00 

PROCTOR.  Practical  Pharmacy.  3d  Edition,  with  Illustrations 
and  Elaborate  Tables  of  Chemical  Solubilities,  etc.  $3.00 

ROBINSON.      Latin  Grammar  of  Pharmacy  and   Medicine. 

3d  Edition.     With  elaborate  Vocabularies.  $1-75 

SAYRE.    Organic  Materia  Medica  and  Pharmacognosy.    An 

Introduction  to  the  Study  of  the  Vegetable  Kingdom  and  the  Vege- 
table and  Animal  Drugs.  Comprising  the  Botanical  and  Physical 
Characteristics,  Source,  Constituents,  and  Pharmacopeial  Prepar- 
ations, Insects  Injurious  to  Drugs,  and  Parmacal  Botany.  With 
sections  on  Histology  and  Microtechnique,  by  W.  C.  Stevens. 
374  Illustrations.     Second  Edition.  Cloth,  J4.50 

SCOVILLE.  The  Art  of  Compounding.  Second  Edition,  Re- 
vised and  Enlarged.  Cloth,  ^2.50 

STEWART.  Compend  of  Pharmacy.  Based  upon  "  Reming- 
ton's Text-Book  of  Pharmacy."  5th  Edition,  Revised  in  Accord- 
ance with  the  U.  S.  Pharmacopoeia,  1890.  Complete  Tables  of 
Metric  and  English  Weights  and  Measures.     .80;    Interleaved,  $1.00 

TAVERA.     Medicinal  Plants  of  the  Philippines.    Just  Ready . 

J  2. 00 

UNITED  STATES  PHARMACOPCEIA.  7th  Decennial  Revision. 
Cloth,  $2. 50  (postpaid,  $2.77) ;  Sheep,  ^3.00  (postpaid,  ;^3. 27) ;  Inter- 
leaved, $4.00  (postpaid,  ;j54.5o);  Printed  on  one  side  of  page  only, 
unbound,  $3.50  (postpaid,  J3.90). 

Select  Tables  from  the  U.  S.  P.     Being  Nine  of  the  Most  Impor- 
tant and  Useful  Tables,  Prmted  on  Separate  Sheets.  .25 

POTTER.  Hand-Book  of  Materia  Medica,  Pharmacy,  and 
Therapeutics.    600  Prescriptions.    8th  Ed.    Clo.,  $5.00;  Sh.,  J6.00 


PHYSIOLOGY. 

BIRCH.  Practical  Physiology.  An  Elementary  Class  Book. 
62  Illustrations.  $1.75 

BRUBAKER.  Compend  of  Physiology.  loth  Edition,  Revised 
and  Enlarged.     Illustrated.  .80;  Interleaved,  Ji. 00 

JONES.  Outlines  of  Physiology.  96  Illustrations.    Nearly  Ready _ 

KIRKES.  Handbook  of  Physiology.  17th  Authorized  Edition. 
Revised,  Rearranged,  and  Enlarged.  By  Prof.  W.  D.  Hallibur- 
ton, of  Kings  College,  London.  681  Illustrations,  some  of  which 
are  in  colors.    Just  Ready.  Cloth,  J3. 00;  Leather,  J3. 75 

2 


SUBJECT  CATALOGUE. 


LANDOIS.  A  Text-Book  of  Human  Physiology,  Including 
Histology  and  Microscopical  Anatomy,  with  Special  Reference  to 
the  Requirements  of  Practical  Medicine.  5th  American,  translated 
from  the  9th  German  Edition,  with  Additions  by  Wm.  Stirling, 
M.D.,D.sc.    845  lUus.,  many  of  which  are  printed  in  colors.   In  Press. 

STARLING.     Elements  of  Human  Physiology.    100  Ills.    Ji.oo 

STIRLING.  Outlines  of  Practical  Physiology.  Including 
Chemical  and  Experimental  Physiology,  with  Special  Reference  to 
Practical  Medicine.     3d  Edition.     289  Illustrations.  ^2.00 

TYSON.     Cell  Doctrine.    Its  History  and  Present  State.        $1.50 


PRACTICE. 

BBALE.    On  Slight  Ailments;  their  Nature  and  Treatment. 

2d  Edition,  Enlarged  and  Illustrated.  $i-25 

FAGGE.     Practice  of  Medicine.      4th    Edition,  by  P.   H.    Pye- 
Smith,  M.D.     2  Volumes.  In  Press. 

FOWLER.  Dictionary  of  Practical  Medicine.  By  various 
writers.  An  Encyclopaedia  of  Medicine.  Clo.,^3.00;  Half  Mor.  I4.00 
GOULD  AND  PYLE.  Cyclopedia  of  Practical  Medicine  and 
Surgery.  A  Concise  Reference  Handbook,  Alphabetically 
Arranged,  with  particular  Reference  to  Diagnosis  and  Treatment. 
Edited  by  Drs.  Gould  and  Pyle,  Assisted  by  72  Special  Con- 
tributors. Illustrated,  one  volume.  Large  Square  Octavo,  Uniform 
with  "  Gould's  Illustrated  Dictionary." 

Sheep  or  Half  Morocco,  gio.oo;  with  Thumb  Index,  $11.00 
Half  Russia,  Thumb  Index,  $12.00 

4®=-  Complete  descriptive  circular  free  upon  application. 

HUGHES.    Compend  of  the  Practice  of  Medicine.    6th  Edition, 
Revised  and  Enlarged. 

Part  I.     Continued,  Eruptive,  and  Periodical  Fevers,  Diseases  of  the 
Stomach,   Intestines,  Peritoneum,  Biliary   Passages,  Liver,  Kid- 
neys, etc.,  and  General  Diseases,  etc. 
Part  II.     Diseases  of  the  Respiratory  System,  Circulatory  System, 
and  Nervous  System;  Diseases  of  the  Blood,  etc. 

Price  of  each  part,  .80;  Interleaved,  $1.00 

Physician's   Edition.      In  one  volume,  including  the  above  two 

parts,  a   Section  on  Skin   Diseases,  and  an  Index.     6th  Revised 

Edition.     625  pp.  Full  Morocco,  Gilt  Edge,  $2.25 

MURRAY.     Rough  Notes  on  Remedies.    4th  Ed.    Just  Ready. 

$1.25 
TAYLOR.  Practice  of  Medicine.  6th  Edition.  Just  Ready.  $4.00 
TYSON.  The  Practice  of  Medicine.  By  James  Tyson,  m.d.. 
Professor  of  Medicine  in  the  University  of  Pennsylvania.  A  Com- 
plete Systematic  Text-book  with  Special  Reference  to  Diagnosis  and 
Treatment.  2d  Edition,  Enlarged  and  Revised.  Colored  Plates  and 
125  other  Illustrations.     1222  Pages.       Cloth,  $5.50;  Leather,  $6.50 


PRESCRIPTION  BOOKS. 

BEASLEY.  Book  of  3100  Prescriptions.  Collected  from  the 
Practice  of  the  Most  Eminent  Physicians  and  Surgeons — English, 
French,  and  American.  A  Compendious  History  of  the  Materia, 
Medica,  Lists  of  the  Doses  of  aU  Officinal  and  Established  Prepara- 
tions, and  an  Index  of  Diseases  and  their  Remedies.     7th  Ed.    $2.00 


MEDICAL  BOOKS.  19 


BEASLEY.  Druggists'  General  Receipt  Book.  Comprising 
a  Copious  Veterinary  Formulary,  Recipes  in  Patent  and  Proprie- 
tary Medicines,  Druggists'  Nostrums,  etc.  ;  Perfumery  and  Cos- 
metics, Beverages,  Dietetic  Articles  and  Condiments,  Trade  Chem- 
icals, Scientific  Processes,  and  an  Appendix  of  Useful  Tables, 
loth  Edition,  Revised.  J2.00 

BEASLEY.  Pocket  Formulary.  ASynopsisof  the  British,  French, 
German,  and  United  States  Pharmacopoeias  and  the  chief  unofficial 
Formularies.     12th  Edition.  $2.00 


SKIN. 

BULKLEY.    The  Skin  in  Health  and  Disease.    Illustrated.    .40 
CROCKER.     Diseases  of  the  Skin.     Their  Description,  Pathol- 
ogy, Diagnosis,  and  Treatment,  with  Special  Reference  to  the  Skin 
Eruptions  of  Children.   92  Illus.   3d  Edition.  Preparing. 

SCHAMBERG.  Diseases  of  the  Skin.  2d  Edition,  Revised  and 
Enlarged.     105  Illustrations.    Being  No.  16  ?  Quiz-Compend?  Series. 

Cloth,  .80;  Interleaved,  Ji.oo 

VAN  HARLINGEN.  On  Skin  Diseases.  A  Practical  Manual 
of  Diagnosis  and  Treatment,  with  special  reference  to  Differential 
Diagnosis.  3d  Edition,  Revised  and  Enlarged.  With  Formulae 
and   60  Illustrations,  some  of  which  are  printed  in  colors.        $2.75 

SURGERY  AND  SURGICAL  DIS- 
EASES (see  also  Urinary  Organs). 

BERRY.  Diseases  of  the  Thyroid  Gland  and  Their  Surgical 
Treatment.     Illustrated.     Just  Ready.  54.00 

BUTLIN.  Operative  Surgery  of  Malignant  Disease.  2d  Edi- 
tion.    Illustrated.     Octavo.  ^4.50 

DEAVER.  Surgical  Anatomy.  A  Treatise  on  Human  Anatomy 
in  its  Application  to  Medicine  and  Surgery.  With  about  400  very 
Handsome  full-page  Illustrations  Engraved  from  Original  Drawings 
made  by  special  Artists  from  Dissections  prepared  for  the  purpose. 
Three  Volumes.     Royal  Square  Octavo. 

Cloth,  J21.00  ;  Half  Morocco  or  Sheep,  $24.00  ;  Half  Russia,  J27.00 
Complete  descriptive  circular  and  special  terms  upon  application. 

DEAVER.  Appendicitis,  Its  Symptoms,  Diagnosis,  Pathol- 
ogy, Treatment,  and  Complications.  Elaborately  Illustrated 
with  Colored  Plates  and  other  Illustrations.     2d  Edition.  $3-5o 

DULLES.  AA^hat  to  Do  First  in  Accidents  and  Poisoning. 
5th  Edition.     New  Illustrations.  $1.00 

FULLERTON.     Surgical  Nursing.     3d  Edition.    6g  Illus.    $1.00 

HAMILTON.     Lectures  on  Tumors.    3d  Edition.  J1.25 

HEATH.  Minor  Surgery  and  Bandaging.  12th  Edition,  Revised 
and  Enlarged.    195  Illus.,  Formulse,  Diet  List,  etc.  Just  Ready.  J1.50 

HEATH.  Injuries  and  Diseases  of  the  Jaws.  4th  Ed.  $4.50 
HOR'WITZ.  Compend  of  Surgery  and  Bandaging,  including 
Minor  Surgery,  Amputations,  Fractures,  Dislocations,  Surgical  Dis- 
eases, and  the  Latest  Antiseptic  Rules,  etc.,  with  Differential  Diagno- 
sis and  Treatment.  5th  Edition,  very  much  Enlarged  and  Rear- 
ranged.   167  Illustrations,  98  Formulae.   Clo.,  .80;  Interleaved,  $1.00 


20  SUBJECT  CATALOGUE. 

JACOESON.    Operations    of    Surgery.    Over  200  Illustrations. 

Cloth,  J83.00  ;  Leather,  $4.00 

KEHR.  Gall-Stone  Disease.  Translated  by  William  Wotkyns 
Seymour,  m.d.     Just  Ready.  S2.50 

LANE.     Surgery  of  the  Head  and  Neck,     no  lUus.  $5.00 

MACREADY.  A  Treatise  on  Ruptures.  24  Full-page  Litho- 
graphed Plates  and  Numerous  Wood  Engravings.  Cloth,  ;^6.oo 

MAKINS.  Surgical  Experiences  in  South  Africa.  1899-1900. 
Illustrated.     Just  Ready.  $4.00 

MAYLARD.  Surgery  of  the  Alimentary  Canal.  97  Illustrations. 
2d  Edition,  Revised.  $3-oo 

MOULLIN.  Text-Book  of  Surgery.  With  Special  Reference  to 
Treatment.  3d  American  Edition.  Revised  and  edited  by  John  B. 
Hamilton,  m.d.,  ll.d..  Professor  of  the  Principles  of  Surgery  and 
Clinical  Surgery,  Rush  Medical  College,  Chicago.  623  Illustrations, 
many  of  which  are  printed  in  colors.     Cloth,  $6.00;  Leather,  $7.00 

SMITH.  Abdominal  Surgery.  Being  a  Systematic  Description  of 
all  the  Principal  Operations.    224  Illus.  6th  Ed.    2  Vols.  Clo.,  $10.00 

VOSWINKEL.  Surgical  Nursing.  Second  Edition,  Revised  and 
Enlarged,     in  Illustrations.  jfi.oo 

WALSHAM.  Manual  of  Practical  Surgery.  7th  Ed.,  Re- 
vised and  Enlarged.   483  Engravings.   950  pages.  ?3.5o 

TEMPERATURE  CHARTS,   ETC. 

GRIFFITH.  Graphic  Clinical  Chart  for  Recording  Temper- 
ature, Respiration,  Pulse,  Day  of  Disease,  Date,  Age,  Sex, 
Occupation,  Name,  etc.  Printed  in  three  colors.  Sample  copies 
free.  Put  up  in  loose  packages  of  fifty,  .50.  Price  to  Hospitals,  500 
copies,  S4-00 ;  1000  copies,  JS7.50.  With  name  of  Hospital  printed 
on,  50  cts.  extra. 

KEEN'S  CLINICAL  CHARTS.  Seven  Outline  Drawings  of  the 
Body,  on  which  may  be  marked  the  Course  of  Disease,  Fractures, 
Operations,  etc.  Each  Drawing  may  be  had  separately,  twenty-five 
to  pad,  1'^  cents. 

SCHREINER.  Diet  Lists.  Arranged  in  the  form  of  a  chart. 
With  Pamphlets  of  Specimen  Dietaries.     Pads  of  50.  .75 

THROAT   AND    NOSE    (see  also  Ear). 

COHEN.     The  Throat  and  Voice.     Illustrated.  .40 

HALL.  Diseases  of  the  Nose  and  Throat.  2d  Edition,  Enlarged. 
Two  Colored  Plates  and  80  Illustrations.    Just  Ready.  $2.75 

HOLLOPETER.     Hay  Fever.     Its  Successful  Treatment,      gi.oo 

KNIGHT.  Diseases  of  the  Throat.  A  Manual  for  Students. 
Illustrated.  Nearly  Ready. 

LAKE.  Laryngeal  Phthisis,  or  Consumption  of  the  Throat. 
Colored  Illustrations.     Just  Ready.  $2  00 

MACKENZIE.  Pharmacopoeia  of  the  London  Hospital  for 
Dis,  of  the  Throat,    sth  Ed.,  Revised  by  Dr.  F.  G.  Harvey.  $1.00 

McBRIDE.  Diseases  of  the  Throat,  Nose,  and  Ear.  With  col- 
ored Illustrations  from  original  drawings.   3d  Edition.  J7.00 

POTTER.  Speech  and  its  Defects.  Considered  Physiologically, 
Pathologically,  and  Remedially  gi.oo 

SHEILD.     Nasal  Obstructions.     Illustrated.    Just  Ready.    $1.50 

URINE  AND  URINARY  ORGANS. 

ACTON.  The  Functions  and  Disorders  of  the  Reproductive 
Organs  in  Childhood,  Youth,  Adult  Age,  and  Advanced  Life, 

Considered  in  their   Physiological,    Social,  and    Moral    Relations. 
Sth  Edition.  gi.75 


MEDICAL  BOOKS. 


BEALE.  One  Hundred  Urinary  Deposits.  On  eight  sheeu, 
for  the  Hospital,  Laboratory,  or  Surgery.  Paper,  $2.00 

HOLLAND.  The  Urine,  the  Gastric  Contents,  the  Common 
Poisons,  and  the  Milk.  Memoranda,  Chemical  and  Microscopi- 
cal, for  Laboratory  Use.   Illustrated  and  Interleaved.    6th  Ed.    $1.00 

KLEEN.     Diabetes  and  Glycosuria.  j2-5o 

MEMMINGER.    Diagnosis  by  the  Urine.   2d  Ed.  24  lUus.   $i.oo 

MORRIS.  Renal  Surgery,  with  Special  Reference  to  Stone  in  the 
Kidney  and  Ureter  and  to  the  Surgical  Treatment  of  Calculous 
Anuria.     Illustrated.  $2.00. 

MOULLIN.  Enlargement  of  the  Prostate.  Its  Treatment  and 
Radical  Cure.     2d  Edition.     Illustrated.  ^i-7S 

MOULLIN.  Inflammation  of  the  Bladder  and  Urinary  Fever. 
Octavo.  Jr-So 

SCOTT.  The  Urine.  Its  Clinical  and  Microscopical  Examination. 
41  Lithographic  Plates  and  other  Illustrations.    Quarto.  Cloth,  ^5.00 

TYSON.  Guide  to  Examination  of  the  Urine.  For  the  Use  of 
Physicians  and  Students.  With  Colored  Plate  and  Numerous  Illus- 
trations engraved  on  wood,     gth  Edition,  Revised.  Ji-2S 

VAN   NUYS.    Chemical  Analysis  of  Urine.    39  lUus.         $1.00 


VENEREAL  DISEASES. 

GOWERS.     Syphilis  and  the  Nervous  System.  $t.oo 

STURGIS   AND    CABOT.      Student's    Manual    of   Venereal 

Diseases.    7th  Revised  and  Enlarged  Ed     i2mo.  Jiist  Ready.  ^1.25 


VETERINARY. 

BALLOU.    Veterinary  Anatomy  and  Physiology.    29  Graphic 
Illustrations.  .80;  Interleaved,  ^i. 00 


WOMEN,  DISEASES  OF. 

BISHOP.     Uterine  Fibromyomata.    Their  Pathology,  Diagnosis, 
and  Treatment.     Illustrated.    Just  Ready.  Cloth,  I3  50 

BYFORD   (H.   T.).     Manual   of  Gynecology.     Second   Edition, 
Revised  and  Enlarged  by  100  pages.     341  Illustrations.  J3.00 

DUHRSSEN.     A  Manual    of   Gynecological    Practice.      105 
Illustrations.  $^-S° 

FULLERTON.     Surgical   Nursing.     3d   Edition,   Revised  and 
Enlarged.     69  Illustrations.  gi.oo 

LEWERS.    Diseases  of  'Women.    146  lUus.    5th  Ed.  J2.50 

MONTGOMERY.      Practical    Gynecology.     A  Complete   Sys- 
tematic Text-Book.    527  Illustrations.     Clotn,  $5.00;  Leather,  $6.00 

ROBERTS.      Gynecological    Pathology.      With   127   Full-page 
Plates  containing  151  Figures.    Just  Ready.  g6.oo 

WELLS.    Compend  of  Gynecology.    Illustrated.    2d  Edition. 

.  80  ;  Interleaved,  Ji .  00 


SUBJECT  CATALOGUE. 


COMPENDS. 


From  The  Southern  Clinic. 

"  We  know  of  no  series  of  books  issued  by  any  house  that  so  fully 
meets  our  approval  as  these  ?Quiz-Compends?.  They  are  well  ar- 
ranged, full,  and  concise,  and  are  really  the  best  line  of  text-books  that 
could  be  found  for  either  student  or  practitioner." 


BLAKISTON'S  ?QUIZ-COMPENDS? 

The  Best  Series  of  Manuals  for  the  Use  of  Students. 
Price  of  each,  Cloth,  .80.         Interleaved,  for  taking  Notes,  $1.00. 

j^~  These  Compends  are  based  on  the  most  popular  text-books 
and  the  lectures  of  prominent  professors,  and  are  kept  constantly  re- 
vised, so  that  they  may  thoroughly  represent  the  present  state  of  the 
subjects  upon  which  they  treat. 

>^g*  The  authors  have  had  large  experience  as  Quiz-Masters  and 
attaches  of  colleges,  and  are  well  acquainted  with  the  wants  of  students. 

O*  They  are  arranged  in  the  most  approved  [form,  thorough  and 
concise,  containing  over  600  fine  illustrations,  inserted  wherever  they 
could  be  used  to  advantage. 

>8^  Can  be  used  by  students  of  any  college. 

49"  They  contain  information  nowhere  else  collected  in  such  a 
condensed,  practical  shape.     Illustrated  Circular  free. 

No.  I.  POTTER.  HUMAN  ANATOMY.  Sixth  Revised  and 
Enlarged  Edition.  Including  Visceral  Anatomy.  Can  be  used 
with  either  Morris's  or  Gray's  Anatomy.  117  Illustrations  and  16 
Lithographic  Plates  of  Nerves  and  Arteries,  with  Explanatory 
Tables,  etc.  By  Samubl  O.  L.  Potter,  m.d..  Professor  of  the 
Practice  of  Medicine,  College  of  Physicians  and  Surgeons,  San 
Francisco  ;  Brigade  Surgeon,  U.  S.  Vol. 

No.  2.  HUGHES.  PRACTICE  OF  MEDICINE.  Part  I.  Sixth 
Edition,  Enlarged  and  Improved.  By  Daniel  E.  Hughes,  m.d., 
Physician-in-Chief,  Philadelphia  Hospital,  late  Demonstrator  of 
Clinical  Medicine,  Jefferson  Medical  College,  Phila. 

No.  3,  HUGHES.  PRACTICE  OF  MEDICINE.  Part  11. 
Sixth  Edition,  Revised  and  Improved.     Same  author  as  No.  2. 

No.  4.  BRUBAKER.  PHYSIOLOGY.  Tenth  Edition,  with 
Illustrations  and  a  table  of  Physiological  Constants.  Enlarged 
and  Revised.  By  A.  P.  Brubaker,  m.d..  Professor  of  Physiology 
and  General  Pathology  in  the  Pennsylvania  College  of  Dental 
Surgery ;  Adjunct  Professor  of  Physiology,  Jefferson  Medical 
College,  Philadelphia,  etc. 

No.  5.  LANDIS.  OBSTETRICS.  Seventh  Edition.  By  Henry  G. 
Landis,  m.d.  Revised  and  Edited  by  Wm.  H.  Wells,  m.d.. 
Demonstrator  of  Clinical  Obstetrics,  Jefferson  Medical  College, 
Philadelphia.     Enlarged.     52  Illustrations. 

No.  6.  POTTER.  MATERIA  MEDICA,  THERAPEUTICS, 
AND  PRESCRIPTION  WRITING.  Sixth  Revised  Edition 
(U.  S.  P.  1890).  By  Samuel  O.  L.  Potter,  m.d..  Professor  of 
Practice,  College  of  Physicians  and  Surgeons,  San  Francisco; 
Brigade  Surgeon,  U.  S.  Vol. 


MEDICAL  BOOKS. 


?  QUIZ-COMPENDS  ?— Continued. 

No.  7.  WELLS.  GYNECOLOGY.  Second  Edition.  ByWM.  H. 
Whlls,  M.D.,  Demonstrator  of  Clinical  Obstetrics,  Jefiferson 
Medical  College,  Philadelphia.     140  Illustrations. 

No.  8.  GOULD  AND  PYLE.  DISEASES  OF  THE  EYE 
AND  REFRACTION.  Second  Edition.  Including  Treatment 
and  Surgery,  and  a  Section  on  Local  Therapeutics.  By  George 
M.  Gould,  m.d.,  and  W.  L.  Pyle,  m.d.  With  Formulae,  Glossary 
Tables,  and  109  Illustrations,  several  of  which  are  Colored. 

No.  9.  HORWITZ.  SURGERY,  Minor  Surgery,  and  Bandag- 
ing. Fifth  Edition,  Enlarged  and  Improved.  By  Orville 
HoRWiTZ,  B.  s.,  M.D.,Clinical  Professor  of  Genito-Urinary  Surgery 
and  Venereal  Diseases  in  Jefferson  Medical  College  ;  Surgeon  to 
Philadelphia  Hospital,  etc.    With  98  Formulae  and  71  Illustrations. 

No.  10.  LEFFMANN.      MEDICAL    CHEMISTRY.      Fourth 

Edition.  Including  Urinalysis,  Animal  Chemistry,  Chemistry  of 
Milk,  Blood,  Tissues,  the  Secretions,  etc.  By  Henry  Leffmann, 
M.D.,  Professor  of  Chemistry  in  the  Woman's  Medical  College  of 
Penna  ;  Pathological  Chemist,  Jefferson  Medical  College  Hospital. 
No.  II.  STEWART.  PHARMACY.  Fifth  Edition.  Based  upon 
Prof.  Remington's  Text-Book  of  Pharmacy.  By  F.  E.  Stewart, 
M.D.,  PH.G.,  late  Quiz-Master  in  Pharmacy  and  Chemistry,  Phila- 
delphia College  of  Pharmacy ;  Lecturer  at  Jefferson  Medical 
CoUege.     Carefully  revised  in  accordance  with  the  new  U.  S.  P. 

No.  12.  BALLOU.  VETERINARY  ANATOMY  AND  PHY- 
SIOLOGY. Illustrated.  By  Wm.  R.  Ballou,  m.d.,  Professor 
of  Equine  Anatomy  at  New  York  College  of  Veterinary  Surgeons  ; 
Physician  to  Bellevue  Dispensary,  etc.     29  graphic  Illustrations 

No.  13.  WARREN.  DENTAL  PATHOLOGY  AND  DEN- 
TAL MEDICINE.  Third  Edition,  Illustrated.  Containing 
a  Section  on  Emergencies.  By  Geo.  W.  Warren,  d.d.s.,  Chief 
ot  Clinical  Staff,  Pennsylvania  College  of  Dental  Surgery. 

No.  1^.  HATFIELD.  DISEASES  OF  CHILDREN.  Second 
Edition.  Colored  Plate.  By  Marcus  P.  Hatfield,  Profes- 
sor of  Diseases  of  Children,  Chicago  Medical  College. 

No.  15.  THAYER.   GENERAL  PATHOLOGY.   By  A.  E. 

Thayer,  m.d.,  Cornell  University  Medical  College.     Illustrated. 

No.  16.  SCHAMBERG.     DISEASES  OF  THE  SKIN.   Second 

Edition.  By  Jay  F.  Schamberg,  m.d..  Professor  of  Diseases  of 
the  Skin,  Philadelphia  Polyclinic.  Second  Edition,  Revised  and 
Enlarged.  105  handsome  Illustrations. 
No.  17.  CUSHING.  HISTOLOGY.  By  H.  H.  Gushing,  m.d.. 
Demonstrator  of  Histology,  Jefferson  INIedical  College,  Philadel- 
phia.    Illustrated. 

No.  18.  THAYER.  SPECIAL  PATHOLOGY.  Illustrated.  By 
same  Author  as  No.  15. 

Price,  each.  Cloth,  .80.  Interleaved,  for  taking  Notes,  $1.00. 

Careful  attention  has  been  given  to  the  construction  of  each  sentence, 
and  while  the  books  will  be  found  to  contain  an  immense  amount  of 
knowledge  in  small  space,  they  will  likewise  be  found  easy  reading ; 
there  is  no  stilted  repetition  of  words  ;  the  style  is  clear,  lucid,  and  dis- 
tinct. The  arrangement  of  subjects  is  systematic  and  thorough ;  there 
is  a  reason  for  every  word.    They  contain  over  600  illustrations. 


THE  STANDARD  TEXT-BOOK 

MORRIS'  Anatomy 

SECOND  EDITION 

Rewritten.    Revised*    Improved 

WITH  MANY  NEW  ILLUSTRATIONS 


Has  been  recommended  as  a  text-book  at  more  than 
seventy  of  tbe  most  prominent  medical  schools  in  the  United 
States  and  Canada,  and  is  considered  by  all  anatomists  as  a 
standard  authority.  It  contains  many  features  of  special 
advantage  to  students.  A  complete  Text-book.  Edited  by 
Henhy  Morris,  r.R.c.s.,  Surgeon  to,  and  Lecturer  on 
Anatomy  at,  Middlesex  Hospital,  assisted  by  J.  Blaxd 
Sutton,  f.r.cs.,  J.  H.  Daties-Colley,  f.r.c.s.,  Wm.  J- 
Wai,sham,  F.R.CS.,  H.  St.  John  Brooks,  m.d.,  R.  ;NLa.r- 
cns  Gttjvn:,  f.r.c.s.,  Arthur  Hensmax,  f.r.c.s.,  Fred- 
erick Treves,  f.r.c.s.,  Wilxiam  Anderson,  f.r.c.s., 
Prof.  W.  H.  A.  Jacobson,  and  Arthur  Robinson,  m.r.c.s. 

Octavo.     With  790  Illustrations,  of  which  a  large  number 
are  printed  in  colors 

CLOTH,  $6.00:    LEATHER.  $7.00 


"The  ever-groTsing  pvopularity  of  the  book  with  teach- 
ers and  students  is  an  index  of  its  value,  and  it  may  safely 
be  recommended  to  all  interested." — From  77ie  Medical 
Record,  New  York. 

"Of  all  the  text-books  of  moderate  size  on  human 
anatom)'  in  the  English  language,  Morris  is  undoubtedly 
the  most  up-to-date  and  accurate." — From  The  Philadel- 
phia Medical  Journal. 

THUMB  INDEX  IN  EACH  COPY 


COLUMBIA   UNIVERSITY 

'J'his  book  is  due  on  the  date  indicated  below,  or  at  the 
expiration  of  a  definite  period  after  the  date  of  borrowing, 
as  provided  by  the  rules  of  the  Library  or  by  special  ar- 
rangement with  the  Librarian  in  charge. 

DATE  BORROWED 

DATE  DUE 

DATE  BORROWED 

1 

DATE  DUE 

m 

^Y     n    » 

C28'638)MS0 

P4:3 

RC548 

Pershins       nervous  and  ment 
The  diagnosis  ot  ner 


ts-l 


